FORM, 709 UNITED STATES Do not write in space below
wv. Fel

US, TREASURY DEPARTMENT GIFT TAX RETURN Serial No.

intimal REVENUE SERVICE
(31 fe f District Director)
Meee RECEIVED CALENDAR YEAR 19...

(To be executed and filed AFTER the close of the calendar year and not later than the
15th day of the following April)

‘Donor (Given name, middle name or initial, surname)

‘ADDRESS

RESIDENCE (domicile) CrnzeNnsHIP

‘A. Have you (the donor), during the calendar year indicated above, without an adequate and full consideration in money or money’s
worth, made any transfer exceeding $8,000 in value (or regardless of value if a future interest) as follows? (Check whether “Yes”
or “No.”)

1. By the creation of a trust 1] Yes 1] No or
the making of additions to a trust previously created © Yes (1 No
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. [] Yes © No
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 power to revest the beneficial title to the property in yourself or to change the beneficiaries or their proportionate
benefits. [ Yes O No
3. By the purchase of a life insurance policy [] Yes  [) No or
the payment of a premium on a previously issued policy [] Yes (J No, the proceeds of which are in cither case payable to a
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. O Yes [] No
By permitting another to withdraw funds from a joint bank account which were deposited by you. [1 Yes © No
. By conveying title to another and yourself as joint tenants. (| Yes © No
. By conveying title to your spouse and yourself as tenants by the entirety or as joint tenants with right of survivorship. [ Yes
(No If “Yes,” see section 8 of the instructions.

7, By the exercise or release of a power of appointment, except as provided in the Gift Tax Regulations, [] Yes 0 No
8. By any other method, direct or indirect. [) Yes [1 No

If the answer is “Yes” to any of the foregoing, such a transfer (other than the creation of a joint tenancy with your spouse in real
property with right of survivorship, or addition thereto, which you do not elect to treat as a gift) should be fully disclosed in
Schedule A.
B. Gifts of husband and wife to third parties—Do you consent to have the gifts made by both you and your spouse to third parties
during the calendar year considered as having been made one-half by each of you? [] Yes (] No (See section 7 of instructions.)

If the answer is “Yes” the following information must be furnished and the consent shown below signed by your spouse.

x

aoe

1, Name of spouse ... _
2. Were you married during the entire calendar year? [] Yes (No

3. If the answer to 2 is “No,” check whether (] married, [] divorced, or [] widowed. Give date —....
4, Will a gift tax return for this calendar year be filed by your spouse? [] Yes (1 No

CONSENT OF SPOUSE
I consent to have the gifts made by both me and my spouse to third parties during the calendar year considered as having been made
one-half by each of us.

Date ..... ... Signature of spouse ....

COMPUTATION OF TAX (See section 18 of instructions)

1. Amount of taxable gifts for year (line j, Schedule A) ..........seeceeeeeeeeneee beveee
2. Total amount of taxable gifts for preceding years (line c, Schedule B) ..........+.seeseeeeeeeeeeeteeeee
3. Total taxable gifts (item 1 plus item 2)............s esse coos

4, Tax computed on item 3............0005 sere e eens eeeeeee

5. Tax computed on item 2
6. Tax on taxable gifts for year (item 4 minus item 5) .

I declare under the penalties of perjury that this return (including any accompanying schedules and statements) has been examined
by me and to the best of my knowledge and belief is a true, correct, and complete return.

(Signature of firm or person other than taxpayer preparing this return) (Signature of taxpayer or other person filing return)

(Address) (Address)

(Date) ~ (Date)


SCHEDULE A—Toial Gifts During Year and Computation of Taxable Gifts

1 | DESCRIPTION OF GIFT, AND DONEE’S NAME AND ADDRESS pamE er

VALUE AT DATE OF
GIFT

$

(a) ‘otal gifts of donor

(b) Less one-half of items

(c) Balance
(d) Gifts of spouse to be included (from line 6 of spouse’s return) (see section 10 of instructions) ...........
(e) Total gifts for year
(f) Less total exclusions not exceeding $3,000 for each donee (except gifts of future interests)

(9)

(h) Deductions (see sections 14, 15, and 16 of instructions) :

Total included amount of gifts for year

(1) Charitable, public, and similar gifts (based on items
exclusions)

(2) Marital deduction (based on items -.-..

(3) Specific exemption claimed
(i) Total deductions (total of lines 1, 2, and 3)

(j)_Amount of taxable gifts for year (line g minus line é)..

$

SCHEDULE B—Returns, Amounts of Specific Exemption, and Taxable Gifts for Preceding Years (subsequen:

to June 6, 1932)

INTERNAL REVENUE DISTRICT IN WHICH PRIOR RETURN WAS FILED AMOUNT toy

CALENDAR
YEAR SPECIFIC EXEMPTION

AMOUNT OF
TAXABLE GIFTS

| 8

(a) Totals for preceding years (without adjustment for reduced specific exemption) . | $

(b) Amount, if any, by which total specific exemption, line «, exceeds $30,000 (see section 17 of instructions) ..

__(¢)____ Total amount of taxable gifts for preceding years (total, last column, line a, plus amount, if any, line b) .

$

h additional sheets of same size)

(if more space is needed,

U.S. GOVERNMENT PRINTING OFFICE: 1959-O~693780