rorm 709 United States Quarterly Gift Tax Return

(Rev. Sept. 1974) (Use with Instructions for Form 709 (Revised December 1973))

Department of the Treasury +

Internal Revenue Service Calendar quarter ending (month and year) P......... ..

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 since the last Form 709 was filed?

A Have you (the donor), during the calendar quarter indicated above (see section 1 of the instructions 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, made any transfer(s) to any one donee exceeding $3,000 in value for the calendar year (or regard-
less of value if a future interest) as follows in items 1 thru 8 below:

1(a) By the creation of a trust for the benefit of a person or persons other than yourself, and with respect to which you re-
tained no power to revest the beneficial title to the property in yourself or to change the beneficiaries: or their propor:
tionate benefits? If “Yes,” attach a copy of the trust instrument.

(b) Or the making of additions to such type trust previously created? . . en
(c) Or by relinquishing every such power that was retained in a previously created trust? ee

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
power to revest the beneficial title to the property in yourself or to change the beneficiaries or their proportionate benefits? . .

3(a) By the purchase of a life insurance policy the proceeds of which are 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? . . . Soe toe Loe

(b) Or the payment of a premium on such type policy previously issued? . Co
(©)_Or by relinquishing every such power that was retained in a previously issued policy?

4 __ By permitting another to withdraw funds from a joint bank account which were deposited by you? .
5 __By purchase and/or conveyance of title to another and yourself as joint tenants?» . . . . 1... se -
By purchase and/or conveyance of 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 section 9 of the instructions . . . . . . + +... _
By the exercise or release of a power of appointment?
8 __ By any other method, direct or indirect?

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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 prop- Y) Y

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

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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 8 of instructions.) . |__|__
If the answer is “Yes,” the following information must be furnished and the consent shown below signed by your spouse. |Y/7, YF

1 Name of spouse 1(a) Social security number Y

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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 section 1 of the instructions) and such gifts are being 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)? wee
4 If the answer to 3 is “No,” check whether [-] married, [] divorced, or [-] widowed; and give date & WWIAWW,

5 Will a gift tax return for this calendar quarter be filed by your spouse? :
Consent of Spouse
loponsent to have the gifts made by both 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 linec, ScheduleB . . . / ee ee ee ee ee
3 Total (item 1 plus item 2) .

4 Tax computed on item 3 (See ‘Table for Computing Gitt Tax” in separate instructions.) eee ee fe,
5 Tax computed on item 2 (See “Table for Computing Gift Tax” in separate instructions.)

6 Balance (item 4 minus item 5) . . . re
7 Credit for foreign gift taxes (See section 21 of instructions.) So ee

8 Tax due (item 6 minus item 7)

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 taxpayer, his declaration is based on all information of which he has any knowledge.

Gignature of taxpayer) ate)

(Signature of preparer other than taxpayer) ~ (Emp. ident. or soc. sec. no.) @ate)

(Address of preparer other than taxpayer)


SCHEDULE A—Computation of Taxable Gifts

alee Donee’s name and address, description of gift, and method of transfer code Donors afiusted Date of Value at date of
1

(a) Total gifts of donor .

(b) Less one-half of items to.

attributable to spouse (See section 11 of instructions.) .

(c) Balance . . . wee woe
(d) Gifts of spouse to be included (from line b of s spouse’s return) "(See s section or of instructions.) .
(e) Total gifts . . . . toe woe wee
(f)_ Less total exclusions not exceeding $3, 000 for the calendar year for each h donee (except gifts of futur
(g) Total included amount of gifts So ee
(h) Deductions (See sections 17, 18, and 19 of instruetions.):

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(1) Charitable, public, and similar gifts (based on items
(2) Marital deduction (based on items to.
(3) Specific exemption claimed .
Total deductions (total of lines 1, 2, and 3)
Amount of taxable gifts (line g minus line i)

, less exclusions) .

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

1 Have you (the donor) filed Gift Tax Returns for prior periods? . . . .[] Yes [No
If “Yes,” follow section 20 of instructions in completing Schedule B below.

Calendar years (prior to 1971)

and calendar quarters (1971 Internal Revenue office where prior return was filed specie ere obtion Fee

(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 20 a!
(c) Total amount of taxable gifts for prior periods (total, last column, line a, plus amount, if ar’

structions.) .
‘ine b) .

(If more space is needed, attach additional sheets of same size.) E.t, #25-1231452

‘Yr US, GOVERNMENT PRINTING OFFICE : 1974—O-559-339