Form 709 United States Gift Tax Return (To be executed and filed after

the close of the calendar year and

(Rev. Feb. 1969)

Department of the Tressury not later than the 15th day of the
Internal Revenue Service Calendar year 19_..... following April)

Donor's first name and middle

ial Donor's last name | Social Security Number

Address (number and street, city, State, and ZIP code)

Residence (domici

A. Have you (the donor), during the calendar year indicated above, without an adequate and full consideration in money or
money's worth, made any transfer exceeding $3,000 in value (or regardless of value if a future interest) as follows? (Check | Yes | No

whether “Yes” or ‘‘No.”’)

1. By the creation of a trust. . . . ee fp
or the making of additions to a trust previously created. 2 2 2. fae es ee
in either case for the benefit of a person or persons other than yoursel, and with respect to which you retained no power to revest the
beneficial title to the property in yourself or to change the beneficiaries or their * proportionate benefits; or by relinquishing € every such power
that was retained in a previously created trust. . . . . . . : :

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. By the purchase of a life insurance policy. . . . Se es
or the payment of a premium on a previously issued poly « a —
the proceeds of which are in either case 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; or by relinquishing
every such power that was retained in a previously issued policy . toes :

4. By permitting another to withdraw funds from a joint bank account which were deposited by you .

to another and yourself as joint tenants .

6. By conveying title to your spouse and yourself as tenants by the entirety or as joint tenants with right of survivorship .
(it "Yes," see section 8 of the instructions).

th _By the exercise or release of a power of appointment, except ‘as provided in the Gift Tax Regulations .
8. By any other method, direct or indirect . _

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

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 year considered as having been made one-half by each of you? (See section 7 of instructions.). .

if the answer is “Yes,” the following information must be furnished and the consent shown below signed by your spouse. YY,
1. Name of spouse _
_ Yj

|

2. Were you married during the entire calendar year? ._ : toe |
3. If the answer to 2 is ‘‘No,” check whether [] married, [] divorced, or nero “widowed ar and give date WMV

4. Will a gift tax return for this calendar year be filed by your spouse? .

Consent of Spouse
I consent to have the gifts made by both me and my spouse to third parties during the calendar year considered as having been made one-half by each of us.

Date ..

Signature of spouse ...

Computation of Tax (See section 19 of instructions)

1. Amount of taxable gifts for year (line j, Schedule A) . :

2. Total amount of taxable gifts for preceding years (line c, Schedule B). Soe
3. Total taxable gifts (item 1 plus item 2). 2. 2 6 ee LS
4. Tax computed on item 3.0... 2. ee ee

5. Tax computed on item 2. . . . Se
6. Tax on taxable gitts for year (tem 4 minus item 5). rs

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.

(Signature of taxpayer) (ate)

(Signature of preparer other than taxpayer) ~~ "(Date)

(Address of preparer other than taxpayer)


SCHEDULE A—Total Gifts During Year and Computation of Taxable Gifts

nueiper Description of gift, and donee’s name and address Donors adiusted | Dats of Value at date of

$ $

(@) Total gifts of donor .

(b) Less one-half of items . to
(c) Balance. . . . oe

(a) Gifts of spouse to be included (from line b of spouse's 's return) (ee section 10 of instructions).
(@) Total gifts for year. . 2. . : :
(f) Less total exclusions not exceeding $3, 000 for each donee (except gifts of future interests) . Soe es
oy Total included amount of gifts for year. 6 ee eg.
(h) Deductions (see sections 15, 16, and 17 of instructions):

. attributable to spouse (see section 10 of instructions) .

(1) Charitable, public, and similar gifts (based on items .
(2) Marital deduction (based on items to
(3) Specific exemption claimed .
(i) Total deductions (total of lines 1, 2, and 3) . So
(j)_Amount of taxable gifts for year (line g minus line i)... . - . - . ) 7) ee eee eee Ig

., less exclusions). 1$

SCHEDULE B—Returns, Amounts of Specific Exemption, and Taxable Gifts for Preceding Years

1. Have you filed Gift Tax Returns for prior years?. . Se ee ee ee ee Eves EF] No
If “Yes,” follow section 18 of instructions in completing Schedule B below.
Calencer Internal Revenue District in which prior return was filed | specie ont ottion Amount of.
$ $
(a) Totals for preceding years (without adjustment for reduced specific exemption). . . . . . | $
(b) Amount, if any, by which total specific exemption, line a, exceeds $30,000 (see section 18 of instructions) . :
() Total amount of taxable gifts for preceding years (total, last column, line a, plus amount, if any, lineb). . . . . «| $

(If more space is needed, attach additional sheets of same size) U.S, GOVERNMENT PRINTING OFFICE : 19§9—O-332-160