corm 5329 Return for Individual

Retirement Savings Arrangement
Peart ercrue Seu (Under Sections 408 or 409 of the Internal Revenue Code) Only This Side of Form is
Pm Attach to Form 1040. Open to Public Inspection

If you have established a retirement savings arrangement you must complete Part | and Part II and attach this
form to your individual income tax return, Form 1040. In addition: (1) if you claim a deduction on your Form 1040
for contributions to your retirement savings arrangement, complete Part III; (2) if you have made contributions in
excess of your allowable limitation for this year or prior years, complete Part IV; (3) if you are not yet age 5915
when you receive a distribution from your retirement savings arrangement which is not due to a disability, a rollover
contribution to another plan or retirement savings arrangement, or the transfer of an amount to a former spouse
under a divorce decree, you must complete Part V; (4) if you are 7014 or older on the last day of the year, see in-
structions to determine if you are required to complete Part VI.

Name

‘Address (Number and street)

City or town, State and ZIP code

If you are not required to filea Form 1040 checkhere . . . - 6 ee ee ee ee we ee ee eee Oo

Individual and Retirement Savings Information

1 Type of individual retirement savings arrangement:

(a) [J Individual retirement account
(b) [J Individual retirement annuity
(c) [J Individual retirement bonds

2 Were you during any part of the year an active participant in a qualified pension, profit-sharing or stock bonus
plan, including a qualified Keogh (HR 10) plan, or were you covered under a section 403(b) annuity or custodial
account or under a government retirement plan other than the Social Security or Railroad Retirement Acts?
(Volunteer firemen and military reservists see specific instructions forline2). . . . . +... + + [Yes [] No

If “Yes,” you are not allowed a deduction for your 1976 contributions to your individual retirement arrangement.

Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief it is true, correct, and complete. If prepared by a person other than the taxpayer, this declaration is based on all information

of which the preparer has any knowledge.

Your signature

Preparer’s identification number

Preparer’s signature (other than taxpayer) eparers Identification numt

Preparer’s address and ZIP code

218-176-1 Form 5329



Form 5329 (1976) This Page Is Not Open to Public Inspection Page 2

[Part Il__] Attach n Copy B of Form 5498 here

Your Social Security Number... : oe
3 If filed by surviving spouse or beneficiary of an individual who created this retirement savings arrangement check here Oo

and enter name and social security number of individual for whom the arrangement was established >

4 Indicate your age as of the end of the year (If you checked item 3 do not complete this item):
(a) [J Under age 5914
(b) [] Age 591% to 7014
(c) [] Over age 701% (if you check item (c) complete Part VI below)

5 (a) If, during the year, you received a distribution of your entire account from a qualified pension, profit-
sharing or stock bonus plan, because either (i) you terminated employment or (ii) your employer
terminated the plan, and you transferred (roiled over) such distribution to your arrangement, check here . . . . []
(b) If you checked (a) did you transfer the entire amount of the distribution (less any amounts you con-
tributed to the qualified plan—see instructions) to your arrangement within 60 days of receipt of such
distribution (or 12/31/76 if (a)(ii) applies and you received such distribution prior to 11/2/76)?. . . [J] Yes [] No
(c) If (b) was “Yes,” complete lines (i) through (iii) below: Month} Day } Year
(i) Date of transfer to arrangement . . 2. ee ee ee ee
(ii) Date distribution was made to you fromthe plan. . 2... ee ee .
(iii) Name of trustee or insurance company to which the transfer was made (If bonds were purchased state ““Bonds”) >.

(4) (i) _ if within one taxable year, you received a distribution of your entire account from your employer's qualified pension,
profit-sharing or stock bonus plan because the plan was terminated by your employer did you:
(A) receive such amount on or after July 4, 1974 but prior to January 1, 1976,
(B) transfer such amount, reduced by the amount of the income tax paid on the distribution on
your 1974 or 1975 income tax return, to an arrangement and
(C) file a claim for refund of such tax paid? (Check “Yes” only if (A), (B) and (C) ALL apply.) . . [] Yes No

(ii) If (d)(i) is “Yes,” and you have received such refund or credit for such tax paid enter: Month} Day
(A) Date refund or credit received . . . . . So ee i

(B) Date refund or amount of credit was contributed to your retirement savings arrangement . .
Note: See Definition C in the Instructions concerning rollover contributions.

Year

6 If, during the year, you transferred any funds from one retirement savings arrangement to another retire- | Month} Day { Year
ment savings arrangement, enter the date of transfer here. . . 2 . - 2 + e+ es + we ew we “
Caution: Such a transfer may be a taxable distribution.

7 If, during the tax year covered by this form, you have entered into a prohibited transaction under section 4975 or borrowed any amount from
your retirement savings arrangement or pledged any part of your arrangement as security for a loan, checkhere . . . . . . . . [J

Note: See instructions for the tax consequences of such transactions.

SGI Computation of Allowable Deduction
(if you have entered into a prohibited transaction under section 4975, do not complete Part Ill or Part
IV for the retirement savings arrangement with which you entered into such prohibited transaction.)

8 Wages, tips and other compensation from Form 1040 (if a joint return do not include compensation of spouse)
(See definition B in the instructions for the meaning of compensation.). . . . +e + + + + :

9 15% of line 8 or $1,500, whichever is lesser (if you are 701% or over or answered “Yes” to line 2, enter zero). . « « « «

10 Amount paid by you or on your behalf under all your retirement savings arrangements (do not include any
amounts which were considered as “rollover contributions,” see lines 5 and 6, or the purchase price of any
individual retirement bonds redeemed within 12 months of their date of purchase (see instructions) or life
insurance portion of your endowment premium as reported on Form 5498 box 6). . a te

11 Allowable deduction, lesser of line 9 or line 10 (enter here and on Form 1040, line 40a)... s )

WG Tax on Excess Contributions

12 Tax on excess contributions (see Part IV of the Specific Instructions if Part Ill, line 10 exceeds line 11). Enter i
tax from worksheet here and on Form 1040, line61_. - . . - - . + + + + + + i

MGR Tax on Premature Distributions

13 Tax on premature distributions (see Part V of the Specific Instructions if you received a distribution from
your retirement savings arrangement before you have attained age 591). Enter tax from worksheet here and
on Form 1040, line 57... - + rere

Tax on Undistributed Re ement Accounts and ‘Annuities

(See Instructions before completing this Part.)
14 Tax based on current year distribution method, see worksheet in Instructions . . . . . « + «© es H
15 Tax based on aggregate distribution methods, see worksheet in Instructions . . . . . . . ee

16 Tax due, lesser of line 14 or 15, enter here and on Form 1040, in your total for line 62. on the dotted line to
the left of the line 62 entry space write “4974 tax," and show the amount... ee ee

e US, GOVERNMENT PRINTING OFFICE: 1976—O-218-176 218-176-1