rom 7QQ United States Gift Tax Return

(Section 6019 of the Internal Revenue Code) (For gifts made after December 31, 1981 and before January 1, 1985)
(Rev. November 1983) ‘ » For ¥ OMB No. 1545-0020

Calendar year 19 _

Department of the Treasury

Internal Revenue Service > For “Privacy Act” Notice, see the Instructions for Form 1040.
Donor’s first name and middle initial Donor's last name Social security number
Address (number and street) Domicile
City, State, and ZIP code Citizenshi
° Yes | No

If the donor died during the year, checkhere ® L] andenterdateofdeath 9.9... WD Ll

Ifyou received an extension of time to file this Form 709, check here ® C1] and attach the Form 4868, 2688, 2350 or extension letter.

Ifyou (the donor) filed a previous Form 709 (or 709-A), has your address changed since the last Form 709 (or 709-A) was filed?

A_ Gifts by husband or wife to third parties —Do you consent to have the gifts made by you and by your spouse to third
parties during the calendar year considered as made one-half by each of you? (See instructions.) woe .
(If the answer is ‘‘Yes,"’ the following information must be furnished and your spouse is to sign the consent shown below. _

If the answer is ‘‘No, ” skip lines 1-5 and go to Schedule A.)
1(a) Name of consenting spouse 1(b) Social security number

2 Were you married to one another during the entire calendar year? (see instructions) .

ae

3. Ifthe answer to 2 is “No,” check whether O] married D1 divorced or CL) widowed, and give date (see instructions) >
4 Willagift tax return for this calendar year be filed by your spouse?

5 Consent of Spouse—I consent to have the gifts made by me and by my spouse to third parties. curing the calendar year 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.

Consenting spouse's signature > Date >

1 Enter the amount from Schedule A, line 13 . Fo ee ee 1

2 Enter the amount from ScheduleB,line3 2... 1 ee ee 2

3 Total taxable gifts (add lines 1 and 2) . . 3

4 Tax computed on amount on line 3 (see Table A in separate instructions) 4

5 Tax computed on amount on line 2 (see Table A in separate instructions) 5

6 Balance (subtract line 5 from line 4) . toe 6

5 7 Enter the unified credit from Table B (see instructions) . 7

S 8 Enter the unified credit against tax allowable for all prior periods (from Sch. 'B, line L col. ©) 8

5

| 9. Balance (subtract amount on line 8 from amount on line 7) . woe 9
iS 10 Enter 20% of the amount allowed as specific exemption after September 8, 1976 and before

im x January 1, 1977 (see instructions) . 2 2 1. ee 10

| 11 Balance (subtract line 10 fromline9) . . . a od

12° Unified credit (enter the smaller of line 6 or line 1. . a i

13 Credit for foreign gifttaxes(seeinstructions) . . 2. 2 6 ee ee ee ee 13

14 Total(addlines12and13). 2... 2. ee ee ee ee LE

15 Balance (subtract line 14 from line 6) (donotenterlessthanzero) . . . ...... 15

16 Gift taxes prepaid with extension of timetofile. . . . tee ee E16

17 _Ifline 16 is less than line 15, enter BALANCE DUE (see instructions)... . . . . . [27

18 __Ifline 16 is greater than line 15,enterAMOUNTTOBEREFUNDED, ... . . . . . . ‘| 18

Please attach the necessary supplemental documents; see instructions.

Under penalties of perjury, I 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. Declaration of preparer (other than donor) is based on all information of which preparer has any knowledge.

Donor's signature Date >

Preparer's signature
(other than donor) Date >

Please attach check or money order here

Preparer’s address
(other than donor) >

For Paperwork Reduction Act Notice, see page 1 of the separate instructions to this form. Form 709 (Rev. 11-83)


Form 709 (Rev. 11-83) Page 2
SCHEDULE A.— Computation of Taxable Gifts (Gifts less medical and educational exclusions—see instructions)

Donee’s name and address and description of gift. If the gift was made by means 5
EE oT eect ene! | bassarem ot eafciai
1
1 Total gifts of donor (seeinstructions) . . 2 2 1. we ee ee 1
2 One-half of items attributable to spouse (see instructions) 2
3 Balance (subtract line 2 from line 1) . woe . 3
4 Gifts of spouse to be included (from line 2 of spouse’s 'sreturn—see instructions) . 4
5 Totalgifts(addlines3and4).. . . toe . 5
6 Total annual exclusions for gifts listed on Schedule A (including line 4) (see instructions) . 6
7 Total included amount of gifts, subtractline6fromline5 2 2 2 2 ee 7 }
Deductions (see instructions)
8 Gifts of interests to spouse for which a marital deduction will be claimed,
basedonitems ___.____--_..--.___e ofScheduleA. . . . 2... 8
9 Exclusions attributabletogiftsonline8. . 2. 2 6 1 we ee 9
10 Marital deduction—subtract line 9 from line 8 10
11 Charitable deduction, based on items . to. i
12  Totaldeductions—addlines10and11. . 2
13 _ Taxable gifts (subtractline 12 fromline7). . . . |

Terminable Interest Marital Deduction. (see instructions)
O < Check here if you elected, under the rules of section 2523(f), to include gifts of qualified terminable interest property on line 8,
above. Enter the item numbers (from Schedule A, above) of the gifts for which you made this election

SCHEDULE B.— Did you (the donor) file gift tax returns for prior periods? (If “Yes,” see instructions for completing Schedule Bbelow.) [J Yes T_No
(a)
(a) (b) Amount Stunited Amount f spec
specific O)
andar duatet, IteralReyene fies Cebtaganctet | _eamplon tapnce am htor
where prior return was filed tax for periods after riods ending before taxable gifts
(see instructions) December 31, 1976_| January 1.1977 8

1. Totals for prior periods (without adjustment for reduced specific exemption) | 1
2 Amount, if any, by which total specific exemption, line 1, column (d), is more than $30,000 . . . ,|_2
3 Total amount of taxable gifts for prior periods (add amount, column (e), line 1, and amount, if any, online 2) . | 3

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