rom 709 United States Quarterly Gift Tax Return

OMB No. 1545-0020

(Rev. November 1981) (Section 6019 of the Internal Revenue Code) (For gifts made after December 31, 1976, and before January 1, 1982) |
Department of the Treasury Calendar quarter(s) ending [] March, [] June, [1] September, [] December, 19......... Expires 9-30-82
Internal Revenue Service > For “Privacy Act” notification, see the Instructions for Form 1040.

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 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 instructions.). . . . . . .
(If the answer is “Yes,” the following information must be furnished and your spouse is to sign the consent shown below. 7 Y

If the answer is “‘No," skip lines 1-6 and go to Schedule A.)
1(a) Name of consenting spouse 1(b) Social security number 7/7
Wy,

IN

Yj

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 instructions) and such gifts are being reported on this return (see instructions), write the
previous quarter(s) ending (month and year) in addition to the current quarter ending (month and year).

3 _Were you married to one another during the entire calendar quarter(s)? .

4 If the answer to 3 is “No,” check whether [~ {] married [7] divorced or [7] widowed, and give date (see instructions) > Yj YU
5 Will a gift tax return for this calendar quarter(s) be filed by your spouse? .

& Consent of Spouse— consent to have the gifts made by me and by my spouse to third parties during the calendar quarter) 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 25... 1 1 ee ee ee
2 Enter the amount from Schedule B, line3. . . 6 ee ee ee ee

3 Total taxable gifts (add amounts on lines 1 and2). . . . . . Soe ee ee
4 Tax computed on amount on line 3 (see Table A in separate instructions) . se ee eee
5 Tax computed on amount on line 2 (see Table A in separate instructions). . . .

= 6 Balance (subtract amount on line 5 from amount on line4). . 6 2 1 ee ee ee

| 7 Enter the amount of unified credit from Table B (see instructions) . toe

|S] 8 Enter the amount of unified credit against gift tax allowable for all prior quarters. . . .
re

=| 9 Balance (subtract amount on line 8 from amount on line7). . ss + + + ee eee

3 | 10 Enter 20% of the amount allowed as specific exemption after September 8, 1976 .

11 Balance (subtract amount on line 10 from amount on line9). . .

12 Unified credit (enter the smaller of amount on line 6 or amount online 11). . . . . .
13 Credit for foreign gift taxes (see instructions). . . 6. / 6 ee ee ee ee
14 Total (add amounts on line 12 and line 13). «© 2 6 ee ee ee sone

~
a ls]a}sle [slo Joo) fon ||| ee

15 Tax due (subtract amount on line 14 from amount on line 6) (see instructions) .

Please attach the necessary supplemental documents; see instructions,

Under f perjury, 1 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 af prepares (other thaw donan ie based on al niermation al which Breparer has any knowledge.

Donor’s signature > Date >

Please attach check or money order here

Preparer’s signature
(other than donor) > Date &

Preparer’s address
(other than donor) >

For Paperwork Reduction Act Notice, see page 1 of the separate instructions to this form. 343-493-2


Form 709 (Rev. 11-81)

Page 2

| Schedule A_| Computation of Taxable Gifts

vinta] umes REE eee Safeco | Sack SP Sah ein
1

1 Total gifts of donor (see instructions). . . . ~ . re oe

2 One-half of items . attributable to spouse (see instructions) . _2 |

3 Balance (subtract amount on line 2 from amount on line 1) . : 3

4. Gifts of spouse to be included (from line 2 of spouse's return—see instructions) . . 4.

5 Total gifts (add amounts on lines 3 and 4). . —s

6 Total exclusions not exceeding $3,000 for the calendar year for ‘each d donee (except gifts of future interests) . _ 6

7 Total included amount of gifts (subtract amount on line 6 from amount on line 5). ~L7

Deductions (see instructions):

8 Gift of qualified interests to spouse for this period (before annual exclusion, based on
items .. . . . from Schedule A). - woe eee
9 Annual ‘exclusion attributable to gifts on line 8.

10 Net amount (subtract amount on line 9 from amount on line ').

11 First $100,000 marital deduction. . . . sone

12 Marital deduction for prior periods after December 31, 976. sone sone

13 Balance of first $100,000 marital deduction available (subtract amount on line 12
from amount on line 11. If less than zero, enter zero). . - woe . .

14 Excess over first $100,000 marital deduction (if total of amount on tine 10 plus
amount on line 12 is $100,000 or less, enter zero. Otherwise, enter amount on line &
less amount on line 13) .

15 Excess over first $100,000 for prior periods (after December 31, 1976) .

16 Total excess over first $100,000 (add amounts on lines 14 and 15) .

17 Second $100,000. . . . eee ee . .

18 Gifts qualifying for additional marital deduction (subtract amount on line 7 from
amount on line 16. If less than zero, enter zero) .

19 Enter 50% of amount on line18. . . . oo oe

20 Enter 50% of amount on line 8 but not more than amount on line to. sone

21 Enter the smaller of the amount on line 10 or the amount online 13. . . . +s

22 Marital deduction (if amount on line 18 is zero, enter amount from line 21. Otherwise,
enter amount from line 21 plus the smaller of the amounts on line 19 or line 20) .

23 Charitable, public, and similar gifts (based on items .....
exclusions). . . ee ee . ee

24 Total deductions (add amounts on lines 22 and 423). cr

25 Amount of taxable gifts (subtract amount on line 24 from amount on lin
returns for prior periods? (If “Ye

iN}

follow instruc

$100,000

$100,000

24

25.
ing ‘Schedule B below.) [] Yes [] No

Os (pri «by ‘Amount ot unified

soGglendar years (prior to, nternal Ravan ofce ceed againgt et
where prior return was file ax for periods after

(971 and subsequent years) tax for periods after

‘Amount'ot specific ©
exemption for prior Amount of
periods ending before taxable gifts

January 1, 1

1 Totals for prior periods (without adjustment for reduced specific exemption) .

2 Amount, if any, by which total specific exemption, line 1, column (d), is more than $30,000 .

3 Total amount of taxable gifts for prior periods (add amount, column (e), line 1, and amount, if any, line 2).

(if more space is needed, attach additional sheets of same size.)
‘te U.S. GOVERNMENT PRINTING OFFICE ; 1981—O-343-493

343-493-3