farm 09 United States Quarterly Gift Tax Return
Department of the Treasury

Per snus Senice Calendar quarter ending (month and year)

Donor’s first name and middle initial Donor's last name Social security number

‘Address (number and street) Residence (domicile)

City, State, and ZIP code Citizenship

if you (the donor) filed a previous Form 709, has your address changed... a .... O Yes [J No

A. Have you (the donor), during the calendar quarter indicated above, without an adequate and full consideration in money or money's
worth, made any transfer exceeding $3,000 in value for the calendar year (or regardless of value if a future interest)? (See section 1 of

the Instructions for treatment of gifts in more than one quarter which aggregate more than $3,000.)

1, Bythe creation ofatrust? © 6.0. 6 ee ee

or the making of additions to a trust previously created?» 2. 2 ee ee ee
in either case for the benefit of a person or persons other than yourself, and with respect to which you retained no power to revest the
beneficial title to the property in yourself or to change the beneficiaries or their proportionate benefits; or by relinquishing every such power
that was retained in a previously created trust? . - ee ee ee ee ae

2. By permitting a beneficiary, other than yourself, to receive the income from a trust created by you and with respect to which you retained
the powor to revest the beneficial title to the property in yourself or to change the beneficiaries or their proportionate benefits? .

3. By the purchase of alife insurance policy?» . . - 6 6 ee ee

or the payment of a premium on a previously issued policy?» +. eee ee
the proceeds of which are in either case payable to 2 beneficiary other than your estate, and with respect to which you retained no power
to revest the economic benefits in yourself or your estate or to change the beneficiaries or their proportionate benefits; or by relinquishing
every such power that was retained in a previously issued policy? - . + + + + ee et tt tt

4. By permitting another to withdraw funds from a joint bank account which were deposited by you?

5. By conveying title to another and yourself as joint tenants?» - - + + +

6. By conveying title to your spouse and yourself as tenants by the entirety or as joint tenants with right of survivorship? . . . 2. - ee
(it “Yes,” see section 9 of the instructions.) Zfyv
7. By the exercise or release of a power of appointment, except as provided in the Gift Tax Regulations?» . - ss see ee |

®. By any other method, direct or indirect?. . - ee ee et

with right of survivorship, or addition thereto, which you do not elect to treat as a gift) should be fully disclosed in Schedule

B. Gifts of husband and wife to third parties.—Do you consent to have the gifts by both you and your spouse to third parties |

during the calendar quarter(s) considered as having been made one-half by each of you? (See section & of instructions.) .
If the answer is “Yes,” the following information must be furnished and the consent shown below signed by your spouse.

1 the answer is “Yas” to any of the foregoing, such a transfer (other than the creation of a joint tenancy with your spouse in real property _ Y V7
‘ W /

1. Name of spouse la. Social Security Number

2. if the consent i
(see section 1 of tho instructions) and such gifts are baing reported on this return (see section 10 of the instructions), state the previous
quarter(s) ending (month and year) in addition to the current quarter ending (month and year).

3. Were you married during the entire calendar quarter(s)?

effective for gifts made in a previous quartor(s) of the calendar year and no return was filed for such previous quarter(s)_

iY

4. If the answer to 3 is “No,” check whether [] married, [] divorced, or [] widowed; and give date

5, Will a gift tax return for this calendar quarter be filed by your spouse?» . + + + ss ee ee ee tt tt

|

Consent of Spouse

1 consent to have the gifts made by bot me and my spouse to third parties during the calendar quarter(s) considered as having been made one-half by each of us.

Signature of spouse . Date

Computation of Tax

1. Enter the amount from line j, Schedule A

2. Enter the amount from line ¢, Sci B oe

3. Total (item 1 plus item 2)... .. 2. - Bo ee
4. Tax computed on item 3 (See ‘Table for Computing Gift Tax" in separate instructions.)

5. Tax computed on item 2 (See “Table for Computing Gift Tax" in separate instructions.)
6. Tax due (item 4 minus item 5). - ee et

Under penalties of pi
correct, and complete, if propared by a person other than taxpayer, hts declaration is based on all information of which he has any knowledge.

} declaro that | have examined this retura, including any accompanying schedules and statements, and to the best of my knowledge and beliaf it is true,

@ignature of taxpayer)

‘(@ate)

(Signature of preparer other than taxpayer) Wate)

(Address of preparer other than ta’

presreerrrst


SCHEDULE A—Computation of Taxable Gifts

number Description of gift, and donee’s name and address [ Posere avis] Peach | «vale age cf
$ $
(2) Total gifts of donor. 2 6. ee ee

(b) Less one-half of items attributable to spouse (see section 11 of instructions)
(©) Balance. © 2. 2 ee ee ee Se
(a) Gifts of spouse to be included (from line b of spouse's return) (see section 11 of instructions) .
(e) Total gifts. . . . soe se eae
(f) Less total exclusions not exceeding $3, 000 for the calendar year for each donee (excent sits of future interests) « soe
(e) Total included amount of gifts . . . . . rt
(h) Deductions (see sections 16, 17, and 18 of instructions):
(1) Charitable, public, and similar gifts (based on items
(2) Marital deduction (based on items ... . to
(3) Specific exemption claimed. . . . . . + +

(i) Total deductions (total of lines 1, 2, and 3). 2 2 1 ee ee ee ee ee
4j)_Amount of taxable gifts (line g minus linei). . - : * .

SCHEDULE B—Returns, Amounts of 7 Specific Exemption, and Taxable Gifts for Prior Periods

1. Have you filed Gift Tax Returns for prior periods? © 2. - - ee ee eee ee
If “Yes,” follow section 19 of instructions in completing Schedule B below.

-Olyes [] No

Calendaryears(priorto 1971) a
‘and calendar quarters (1971 Internai Revenue office where prior return was filed Amount of
‘and subsequent years) specific exemption

Amount of
taxable gifts

(a) Totals for prior periods (without adjustment for reduced specific exemption) . . . . $

(b) Amount, if any, by which total specific exemption, line a, exceeds $30,000 (see section 19 of instructions) . . . . . -

(©) Total amount of taxable gifts for prior periods (total, last column, line a, plus amount, if any, line b) . . . . «

$.

$

(If more space is needed, attach additional sheets of same size.) [rte—81465-1 U.S, GOVERNMENT PRINTING OFFICE