Form 709 (Rev. 10-90) Page 4
Part 2.—GST Exemption Reconciliation (Code section 2631) and Section 2652(a)(3) Election

Check box [] if you are making a section 2652(a)(3) (special QTIP) election (see instructions)
Enter the item numbers (from Schedule A) of the gifts for which you are making this election >
1 Maximum allowable exemption . . 1 $1,000,000
2 Total exemption used for periods before filing this return . 2
3 > Exemption available for this return (subtract line 2 from line 1) . 3
4 Exemption claimed on this return (from Part 3, col. C total, below) . . . oe .L4
5 Exemption allocated to transfers not shown on Part 3, below. You must attach a Notice ot Allocation (See

instructions.) . 5
6 Addlines4and5 © 6 ee eee LB
7__ Exemption available for future transfers (subtract line6fromline3) . . . . . . .
Part 3.—Tax Computation

A B c D E F G 4

Item No. Net transfer GST Exemption | Dividecol.C | Inclusion Ratio Maximum Estate | Applicable Rate Generation-Skipping
(from Schedule | (from Schedule C, Allocated bycol.B | (subtract col. D Tax Rate (multiply col. E Transfer Tax

C, Part 1) Part 1, col. F) from 1.000) by col. F) (multiply col. B by col. G)

% (

55% ¢ 55)
Tota! exemption claimed. Enter
here and on line 4, Part 2, Total generation-skipping transfer tax. Enter here, on line 14

above. May not exceed line 3, of Schedule A, Part 3, and on line 16 of the Tax ax Computation
Part2,above . . on page 1 . .

(If more space is needed, attach additional sheets of same size.) +#U.S. GPO:1991-518-940/20362



rom 709 United States Gift (and Generation-Skipping Transfer) Tax Return

(Rev, October 1990) (Section 6019 of the Internal Revenue Code) (For gifts made after December 31, 1989, and before January 1, 1993) | OMB No. 1545-0020

Department of the Treasury Calendar year 19 _ Expires 6-31-93
Internal Revenue Service > See separate instructions. For Privacy Act Notice, see the Instructions for Form 1040.

1 Donor’s first name and middle initial 2 Donor's last name 3 Social security number

4 Address (number, street, and apartment number) 5 Domicile

6 City, state, and ZIP code 7 Citizenship

8 If the donor died during the year, check here> C] andenterdateofdeath 119 . [Yes | No

9 Ifyou received an extension of time to file this Form 709, check here > L] and attach the Form 4868, 2688, 2350, or extension letter.
10 Enter the total number of separate donees listed on Schedule A—count each person only once.
111. If you (the donor fled a previous Form 709 (or 709-A), has your address changed since the last Farm 709 (or 709-A) was filed?

12 Gifts by husband or wife to third parties —Do you consent to have the gifts (including generation-skipping transfers)
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.) (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 13-18 and go to Schedule A.). soe ee

13 Name of consenting spouse I 14 SSN

15 Were you married to one another during the entire calendar year? (See instructions.) . woe _

16 If the answer to 15 is ‘'No,"’ check whether (] married [1 divorced or LC) widowed, and give date (see insiuctions) >

117 Willa gift tax return for this calendar year be filed by your spouse? . I

18 Consent of Spouse—I consent to have the gifts (and generation-skipping transfers) made by me and by my spouse to third parties during 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.

Part 1.—General Information

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. 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 >

|Consenting spouse's signature > Date >
1 Enter the amount from ScheduleA, Part3,line15 2 2 2 2. 1... LE
2 Enter the amount from Schedule B, line 3 2
3. Total taxable gifts (addlines1and2). . . . . 3
4 Tax computed on amount on line 3 (see Table for Computing Tax it in separate instructions) 4
5 Tax computed on amount on line 2 (see Table for Computing Tax in separate instructions) 5
6 Balance (subtract line5 fromline4) . 2. . . Soe ee ee LE
c 7 Maximum unified credit (nonresident aliens, see instructions) . . LZ 192,800] 00
Fa 8 Enter the unified credit against tax allowable for all prior periods (from Sch. B, line 1, col. ©) . Ls
| 9 Balance (subtract line 8 from line 7) . Lo . 9
Bl 10 Enter 20% (.20) of the amount allowed as a "specific ‘exemption for gifts ‘made after
& September 8, 1976, and before January 1, 1977 (see instructions). . . . . . . 10
S| 11 Balance (subtract line 10 from line 9) Lo Ce . . LAL
S| 12 Unified credit (enter the smaller of line 6 or line 1). ee
|| 13. Credit for foreign gifttaxes (see instructions) . . . 2 2 2 2 2... La
ini
§] 14 Total credits (addlines12and13). . . cee ees LMA
mS 15 Balance (subtract line 14 from line 6) (do not enter less than zero) Soe ee ee LAS
2 16 Generation-skipping transfer taxes (from Schedule C, Part3,col.H, total). . . . . . . L16
iy
B) | 17 Total tax (addlines 15 and16). . . ee
3 18 Gift and generation-skipping transfer taxes prepaid with extension of time to file 2... [18
e
3
£ 19 Ifline 18 is less than line 17, enter BALANCE DUE (see instructions) . . . . . . . . LID
s
3 20 __ If line 18 is greater than line 17, enter AMOUNTTOBEREFUNDED. . . . . . 20
s
=
o
8
=
s
g
Ss
2
o

Preparer's address
(other than donor) >

For Paperwork Reduction Act Notice, see page 1 of the separate instructions for this form. Form 709 (Rev.10-90)


Form 709 (Rev. 10-90)
Sela eeae.y Computation of Taxable Gifts
Part 1.—Gifts Subject Only to Gift Tax. Gifts /ess political organization, medical, and educational exclusions—see instructions

Page 2

Item

B c D
Donee’s name, relationship to donor (if any), and address and description of Donor's adjusted Date

number | gift. If the gift was made by means of a trust, enter trust's identifying number basis of gift of gift

below and attach a copy of the trust instrument. If the gift was securities,
enter the CUSIP number(s), if available.

E
Value at
date of gift

Part 2.—Gifts Which are Direct Skips and are Subject to Both Gift Ta:

x and Generation-Skipping Transfer Tax. You must list the gifts

in chronological order. Gifts less political organization, medical, and educational exclusions—see instructions. (Also list here direct skips

E
Value at

that are subject only to the GST tax at this time as the result of the termination of an “estate tax inclusion period.” See instructions.)
B D
Item | Donee's name, relationship to donor (if any), and address and description of Donor's adjusted Date
number | gift. Ifthe gift was made by means of a trust, enter trust’s identifying number basis of gift of gift

below and attach a copy of the trust instrument. If the gift was securities,
enter the CUSIP number(s), if available.

date of gift

Part 3.—Gift Tax Reconciliation

1
2
3
4
5

6
7

Deductions (see instructions)

9
10
ll
12
13
14
15

Total value of gifts of donor (add column E of Parts 1 and 2)
One-half of items
Balance (subtract line 2 from line 1) . .
Gifts of spouse to be included (from Schedule A, Part 3, ‘line 2 ‘of spouse's return—see instructions).
If any of the gifts included on this line are also subject to the generation-skipping transfer tax, check
here » (J and enter those gifts also on Schedule C, Part 1.

Total gifts (add tines 3 and 4) . .

Total annual exclusions for gifts listed on Schedule A (including line 4, above) ‘(see instructions)

Total included amount of gifts (subtract line 6 from line 5).

_ attributable to spouse (see instructions)

Gifts of interests to spouse for which a marital deduction will be claimed,
based on items ofScheduleA . . . | 8

a

Exclusions attributable togiftsonline8. . . . ........C9%

Marital deduction—subtract line9fromline8 . 2 . . . . . . . [20

Charitable deduction, based on items _ lessexclusions . LI

Total deductions—add lines 10 and 11 .

Subtract line 12 from line 7.

Generation-skipping transfer taxes payable with this Form 709 (from Schedule C, Part 3, col. H, Total)
Taxable gifts (add lines 13 and 14). Enter here and on line 1 of the Tax Computation on page 1 .

12

13

14

15

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


Form 709 (Rev. 10-90) Page 3
Sea ey Computation of Taxable Gifts (continued)

16 Terminable Interest (QTIP) Marital Deduction. (See instructions.)

1 < Check here if you elected, under the rules of section 2523(f), to include gifts of qualified terminable interest property on line 8,

on page 2. Enter the item numbers (from Schedule A) of the gifts for which you made this election P____.___.___...--..--------eeeeeeee
17 Election out of QTIP Treatment of Annuities

1 < Check here if you elect under section 2523(f)(6) to NOT treat as qualified terminable interest property any joint and survivor
annuities that are reported on Schedule A and would otherwise be treated as qualified terminable interest property under section 2523(f).
(See instructions.) Enter the item numbers (from Schedule A) for the annuities for which you are making this election >

Saas} Gifts From Prior Periods

Did you (the donor) file gift tax returns for prior periods? (If “Yes,” see instructions for completing Schedule Bbelow.). . . . . . . . . CL) Yes O No
c D
A ,
B Amount of unified Amount of specific E
Calendar year or Internal Revenue office credit against gift exemption for prior Amount of
ee instructions) where prior return was filed tax for periods after periods ending before taxable gifts
December 31, 1976 January 1, 1977

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. . . . . L2
3. Total amount of taxable gifts for prior periods (add amount, column E, line 1, and amount, if any, on line °2)
(Enter here and on line 2 of the Tax Computation on pagel.) . . . 3

tei 8 ey §=Computation of Generation-Skipping Transfer Tax

Note: /nter vivos direct skips which are completely excluded by the GST exemption must still be fully reported
(including value and exemptions claimed) on Schedule C.

Part 1.—Generation-Skipping Transfers

ItemN Mt spit be E Net Transt

Item No. Value split Gifts ransfer

(from Schedule A, (from Schedule A, (enter ¥2 of col. B) Subtract co}, Nontaxable portion (subtract col. E
Part 2, col. A) Part 2, col. E) (Gee instructions) ‘rom col. D)

If you elected gift splitting and your spouse Split gifts from Value included
was required to file a separate Form 709 (see spouse's Form 709 from spouse's
the instructions for “Split Gifts”), you must (enter item number) Form 709

enter all of the gifts shown on Schedule A,
Part 2, of your spouse's Form 709 here.

In column C, enter the item number of each
gift in the order it appears in column A of your
spouse's Schedule A, Part 2. We have
preprinted the prefix “S-" to distinguish your
spouse's item numbers from your own when
you complete column A of Schedule C, Part 3.

In column D, for each gift, enter the amount
reported in column C, Schedule C, Part 1, of
your spouse's Form 709.

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