rorm 709 United States Quarterly Gift Tax Return

(Rev. Sept. 1975) (Section 6019 of the Internal Revenue Code)

Department of the Treasury :

Internal Revenue Service Calendar quarter ending (month and year) D>... -
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

Yes | No

If you (the donor) filed a previous Form 709, has your address changed since the last Form 709 was filed? .

A Did you (the donor), during the calendar quarter written above (see instruction 1 for treatment of gifts in more than
one quarter which aggregate more than $3,000), without adequate and full consideration in money or money's worth,
give to any one donee more than $3,000 in value for the calendar year (or regardless of value if a future interest) as
follows in items 1 through 8 below:

1(a) by creating a trust for the benefit of a person or persons other than yourself in which you kept no power to revest the
beneficial title to the property in yourself or to change th the beneficiaries or their ir proportionate | benefits? at “Yes,” attach
a copy of the trust instrument.) . a . : . toe

(b) by adding to such type trust previously created? te :
(©)_by relinquishing every such power that was retained in a previously created trust?

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2 by permitting a beneficiary, other than yourself, to receive the income from a trust you created in which you kept the power to revest the
beneficial title to the property in yourself or to change the beneficiaries or their proportionate benefits? _.

3(@) by purchasing a life insurance policy with proceeds payable toa beneficiary other than your estate in which you kept no
power to revest the economic benefits in yourself or your estate or to change the beneficiaries or their proportionate
enefits? 2... oe : an

(b) by paying a premium on such type policy previously issued? . . .
(©)_by relinquishing every such power that you kept in a previously issued policy? . :

4___by permitting another to withdraw funds that you deposited in a joint bank account? .

5 by purchasing and/or conveying title to real property to your spouse and yourself as tenants by the entirety ¢ or as joint

tenants with right of survivorship? (If “Yes,” see instruction 9.) . - .

6 __ by purchasing and/or conveying title to any other property to another and yourself as “joint t tenants?

7__by exercising or releasing a power of appointment? _.

8 __by any other method, direct or indirect?

If the answer Is “Yes” to any of the foregoing, each gift (other than the creation of a joint tenancy with your spouse in real property with Y Y
right of survivorship, or addition thereto, which you do not elect to treat as a gift) must be fully disclosed in Schedule A. Y Wh Wi
B Gifts by husband or wife to third parties ——Do you consent to have the gifts by you and by your spouse to third parties

during the calendar quarter(s) considered as made one-half by each of you? (See instruction 8.) . .
(if the answer is “Yes,” the following information must be furnished and the consent shown below signed byy your 7 spouse.) Wii

VLA,
1(a) Name of spouse 1(b) Social security number Y/ YY

2 If the consent is effective for gifts made in a previous quarter(s) of the calendar year and no return was filed for such previous quarter(s) (see in-

struction 1) and such gifts are being reported on this return (see instruction 10), write the previous quarter(s) ending (month and year) in addition 7) 77)
to the current quarter ending (month and year). YW

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3 Were you married during the entire calendar quarter(s)? soe ee
4 If the answer to 3 is “No,” check whether {J married, (] divorced, or 7 widowed, and ave date > YW YY

5 Will a gift tax return for this calendar quarter be filed by your spouse?

Consent of Spouse—I consent to have the gifts made by me and by my spouse to third parties during the calendar quarter(s) considered as made one-half by
each of us. We are both aware of the joint and several liability for tax created by the execution of this consent.

Spouse’s signature > Date >

1 Enter the amount from Schedule A, line j

2 Enter the amount from Schedule B, line c . . ;

3 Total (add amounts on linesland2). 2. 2 2. ee ee ee
4 Tax computed on amount on line 3 (See “Table for Computing Gift Tax” in separate instructions.)

5 Tax computed on amount on line 2 (See “Table for Computing Gift Tax”’ in separate instructions.) .
6 Balance (subtract amount on line 5 from amount on line 4)

7 Credit for foreign gift taxes (see instruction 20) .

8 Tax due (subtract amount on line 7 from amount on line 6)

Please attach the necessary supplemental documents; see instruction 15.

Under penalties of perjury, | declare that | have examined this return, including any 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 donor, this declaration 1s based on all information of which the preparer has any knowledge.

Computation of Tax
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Donor’s signature Date

Preparer’s signature (other than donor) Date

Preparer’s address (other than donor)


SCHEDULE A—Computation of Taxable Gifts

Item Donee’s name and address, description of gift, and numerical subpart of question | Donor’s adjusted Date of Value at date of
number ‘A on page 1 where gift was disclosed, such as Al(a) or A3(a) basis of gift gift gift
1

(a) Total gifts of donor . :
(b) One-half of items ............ to ..
« .
(d) Gifts of spouse to be included (from line b of spouse's return) (see instruction 11) -
(e) Total gifts (add amount on lines c and d) an
(f) Total exclusions not exceeding $3,000 for the calendar year 1 for each donee e (except ‘ifts of future interests) .
(g) Total included amount of gifts (subtract amount on line f from amount on line e) .
(h) Deductions (see instructions 16, 17, and 18):
(1) Charitable, public, and similar gifts (based on items
(2) Marital deduction (based on items . to.
(3) Specific exemption claimed a
(i) Total deductions (add amounts on lines 1, 2, and 3) . a
()_Amount of taxable gifts (subtract amount on line i from amount on line g) .

- ‘attributable to spouse (see instruction ‘
Balance (subtract amount on line b from amount on line a) .

- tO... less exclusions) .

).

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

1 Did you (the donor) file gift tax returns for prior periods? . - (Yes [No
(If “Yes,” follow instruction 19 in completing Schedule B below.)

Calendar years (prior to 1971) u

and calendar quarters (1971 Internal Revenue office where prior return was filed specie eerontion Cee tits

(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 instruction 19) . sone
(c) Total amount of taxable gifts for prior periods (add amount, last column, line a, and amount, if any, line b) .

(If more space is needed, attach additional sheets of same size.)