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A. Have you (the donor), durin the calendar year indicated above, without an adequate and full consideration in mane or money’sworth, made any transfer excee ’ng $3,000 in value (or regardless of value if a future interest) u follows? (Check w ether "Yes"01. “No.")

1. By the creation of a trust ............ . ........ L] Yes

$0or the making of additions to a trust previously created .................................................... D Yes No

in either case for the benefit of a person or persons other than yourself, and with respect to which you retained no power to revest thebeneficial 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 ...................... D Yes No

2. By permitting a beneficiary, other than yourself, to receive the income from a trust created by you and with respect to which you

getaigedthe power to revest the beneficial title to the property in yourself or to change the beneficiaries or their proportio

I?ene ts ................................................................................................ D Yes 0

3. By the purchase of a life insurance policy ................................................................ E] Yes [D/Noor the payment of a premium on a previously issued policy. . . D Yes Nothe proceeds of which are in either case payable to a beneficiary other than your estate. and with respect to which you retained 0

power to revest the economic benefits in yourself or your estate or to change the beneficiaries or their proportionate benefiting/nor by relinquishing every such power that was retained in a previously issued policy .. . .. . D Yes

{104. By permitting another to withdraw funds from a joint bank account which were deposited by you .............. [:1 Yes

[{No5. By conveying title to another and yourself as joint tenants .................................................. [I Yes No

6. By conveying title to your spouse and yourself as tenants by the entirety or as joint tenants with right of survi I‘-

ship ................................................................................................... D Yes No

If “Yes," see section 8 of the instructions.

E/7. By the exercise or release of a power of appointment, except as provided in the Gift Tax Regulations .......... E] s No

8. By any other method, direct or indirect .................................................................. Yes D No

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

B. Gifts of husband and wife to third parties—Do you consent to have the gifts made by both you and your spouse third partiesduring the calendar year considered as having been made one-half by each of you? (See sec. 7 of instructiona.).. Yes I] No

If the answer is "Yes” the following information must be mished and the consent shown below signed by your spouse.

1. Name of spouse . :I:2. Were you married during the entire calendar year

3. If the answer to 2 is “No,” check whether [I married, I] divorced, or D widowed. Give date .

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

CONSENT 0F 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 1', Schedule A) .................................................

2. Total amount of taxable gifts for preceding years (line c, Schedule B) . . . .................

3. Total taxable gifts (item 1 plus item 2) . . . , . . ........... . . . . .

4. Tax computed on item 3 ..........................................................................

5. Tax computed on item 2 .......................... . ......... . ................ .. .............. . .. .

6. Tax on taxable gifts for year (item 4 minus item 5) . .

Under penalties of perjury, I declare that l 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.

X (Date)(Signature o! mpsyer)

(Signature of preparer other than taxpayer) (Date)

(Addrul of preparer other than taxpayer)

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