Form 8038 Information Return for Tax-Exempt Private Activity Bond

Form

8038

(Rev. April 2011)

Department of the Treasury
Internal Revenue Service

Part I
1

Information Return for Tax-Exempt
Private Activity Bond Issues

Reporting Authority

Check if Amended Return
2

Issuer’s name

3a

OMB No. 1545-0720

(Under Internal Revenue Code section 149(e))
▶ See separate instructions.

Name of person (other than issuer) with whom the IRS may communicate about this return (see instructions)

3b Telephone number of other person shown on 3a
5 Report number (For IRS Use Only)

4

Number and street (or P.O. box if mail is not delivered to street address)

6

City, town, or post office, state, and ZIP code

7

Date of issue (MM/DD/YYYY)

8

Name of issue

9

CUSIP number

Room/suite

▶

Issuer’s employer identification number

1

10a Name and title of officer or other employee of the issuer whom the IRS may call for more information

Part II
11
a
b
c
d
e
f

g
h

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j
k
l
m
n
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p
q
12a
b
13
14
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16
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18
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20a
b
c

10b Telephone number of officer or other employee shown on 10a

Type of Issue (Enter the issue price.)

Issue Price

Exempt facility bond:
Airport (sections 142(a)(1) and 142(c)) . . . . . . . . . . . . . . . . . . .
Docks and wharves (sections 142(a)(2) and 142(c)) . . . . . . . . . . . . . .
Water furnishing facilities (sections 142(a)(4) and 142(e)) . . . . . . . . . . . .
Sewage facilities (section 142(a)(5)) . . . . . . . . . . . . . . . . . . .
Solid waste disposal facilities (section 142(a)(6)) . . . . . . . . . . . . . . .
Qualified residential rental projects (sections 142(a)(7) and 142(d)) (see instructions) . . .
Meeting 20–50 test (section 142(d)(1)(A))
. . . . . . . . . . . .
Meeting 40–60 test (section 142(d)(1)(B))
. . . . . . . . . . . .
Meeting 25–60 test (NYC only) (section 142(d)(6)) . . . . . . . . . .
Has an election been made for deep rent skewing (section 142(d)(4)(B))? . .
Yes
Facilities for the local furnishing of electric energy or gas (sections 142(a)(8) and 142(f)) . .
Facilities allowed under a transitional rule of the Tax Reform Act of 1986 (see instructions) .
Facility type
1986 Act section
Qualified enterprise zone facility bonds (section 1394) (see instructions) . . . . . . .
Qualified empowerment zone facility bonds (section 1394(f)) (see instructions) . . . . .
District of Columbia Enterprise Zone facility bonds (section 1400A) . . . . . . . . .
Qualified public educational facility bonds (sections 142(a)(13) and 142(k)) . . . . . .
Qualified green building and sustainable design projects (sections 142(a)(14) and 142(l)) . .
Qualified highway or surface freight transfer facilities (sections 142(a)(15) and 142(m)) . . .
Other (see instructions)
Qualified New York Liberty Zone bonds (section 1400L(d))
Other (see instructions)
Qualified mortgage bond (section 143(a)) . . . . . . . . . . . . . . . . .
Other (see instructions)
Qualified veterans’ mortgage bond (section 143(b)) (see instructions) . . . . . . . .
Check the box if you elect to rebate arbitrage profits to the United States
. . . . .
Qualified small issue bond (section 144(a)) (see instructions) . . . . . . . . . . .
Check the box for $10 million small issue exemption
. . . . . . . . . . . .
Qualified student loan bond (section 144(b)) . . . . . . . . . . . . . . . .
Qualified redevelopment bond (section 144(c))
. . . . . . . . . . . . . . .
Qualified hospital bond (section 145(c)) (attach schedule—see instructions) . . . . . .
Qualified 501(c)(3) nonhospital bond (section 145(b)) (attach schedule—see instructions) . .
Check box if 95% or more of net proceeds will be used only for capital expenditures . ▶
Nongovernmental output property bond (treated as private activity bond) (section 141(d)) .
Other (see instructions)
New York Liberty Zone advance refunding bond (section 1400L(e)) (see instructions)
Other. Describe (see instructions) ▶

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 49973K

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11a
11b
11c
11d
11e
11f

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No
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11g
11h

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11i
11j
11k
11l
11m
11n

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11p
11q
12a
12b
13

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14

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20b
20c
Form

8038 (Rev. 4-2011)

Page 2

Form 8038 (Rev. 4-2011)

Part III

Description of Bonds (Complete for the entire issue for which this form is being filed.)
(a) Final maturity date

(b) Issue price

21

$

Part IV
22
23
24
25
26
27
28
29
30

(c) Stated redemption
price at maturity

(d) Weighted
average maturity

years

$

%

Uses of Proceeds of Issue (including underwriters’ discount)

Amount

Proceeds used for accrued interest . . . . . . . . . . . . . . . . . .
Issue price of entire issue (enter amount from line 21, column (b)) . . . . . . . .
Proceeds used for bond issuance costs (including underwriters’ discount)
24
Proceeds used for credit enhancement . . . . . . . . . . . .
25
Proceeds allocated to reasonably required reserve or replacement fund .
26
Proceeds used to currently refund prior issue (complete Part VI) . . . .
27
Proceeds used to advance refund prior issue (complete Part VI) . . . .
28
Add lines 24 through 28 . . . . . . . . . . . . . . . . . . . . . .
Nonrefunding proceeds of the issue (subtract line 29 from line 23 and enter amount here)

Part V

(e) Yield

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22
23

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29
30

Description of Property Financed by Nonrefunding Proceeds
Caution: The total of lines 31a through e below must equal line 30 above. Do not complete for qualified student loan
bonds, qualified mortgage bonds, or qualified veterans’ mortgage bonds.

31
a
b
c
d
e
32

Type of Property Financed by Nonrefunding Proceeds:
Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31a
Buildings and structures . . . . . . . . . . . . . . . . . . . . . . . . .
31b
Equipment with recovery period of more than 5 years . . . . . . . . . . . . . . .
31c
Equipment with recovery period of 5 years or less . . . . . . . . . . . . . . . .
31d
Other. Describe (see instructions)
31e
North American Industry Classification System (NAICS) of the projects financed by nonrefunding proceeds.
NAICS Code

a
b

Part VI
33
34
35
36

Amount of nonrefunding proceeds

$
$

NAICS Code

c
d

Amount of nonrefunding proceeds

$
$

Description of Refunded Bonds (Complete this part only for refunding bonds.)

Enter the remaining weighted average maturity of the bonds to be currently refunded .
Enter the remaining weighted average maturity of the bonds to be advance refunded .
Enter the last date on which the refunded bonds will be called . . . . . . . .
Enter the date(s) the refunded bonds were issued ▶

Part VII

Amount

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years
years

▶
▶

/

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▶

Miscellaneous

37

Name of governmental unit(s) approving issue (see the instructions) ▶

38
39
40a
b
c
d
41
42a
b
c
43

Check the box if you have designated any issue under section 265(b)(3)(B)(i)(III) . . . . . . . . . . . .
Check the box if you have elected to pay a penalty in lieu of arbitrage rebate . . . . . . . . . . . .
Check the box if you have identified a hedge and enter the following information . . . . . . . . . . .
Name of hedge provider
Type of hedge ▶
Term of hedge ▶
Check the box if the hedge is superintegrated . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount of gross proceeds invested or to be invested in a guaranteed investment contract (GIC) ▶
/
Enter the final maturity date of the GIC . . . . . . . . . . . . . . . . . . . . . . ▶
Enter the name of the GIC provider ▶
Check the box if the issuer has established written procedures to ensure that all nonqualified bonds of this
remediated in accordance with the requirements under the Code and Regulations (see instructions) . . . . .

44
45a
b
46

Check the box if the issuer has established written procedures to monitor the requirements of section 148
. . . . ▶
▶
Enter the amount of reimbursement if some portion of the proceeds was used to reimburse expenditures .
/
/
Enter the date the official intent was adopted . . . . . . . . . . . . . . . . . . . . ▶
Check the box if the issue is comprised of qualified redevelopment, qualified small issue, or exempt facilities bonds and
provide name and EIN of the primary private user
. . . . . . . . . . . . . . . . . . . . . . . ▶
Name ▶

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issue are
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EIN
Form

8038 (Rev. 4-2011)

Page 3

Form 8038 (Rev. 4-2011)

Part VIII
47
48
49
a
b
c
d
50a
b
51a
b
52

Volume Caps

Amount

Amount of state volume cap allocated to the issuer. Attach copy of state certification . . . .
Amount of issue subject to the unified state volume cap . . . . . . . . . . . . . .
Amount of issue not subject to the unified state volume cap or other volume limitations:
Of bonds for governmentally owned solid waste facilities, airports, docks, wharves, environmental
enhancements of hydroelectric generating facilities, or high-speed intercity rail facilities . . . .

47
48
49
49a
49b
49c
49d
50a
50b
51a

Under a carryforward election. Attach a copy of Form 8328 to this return . . . . . . . . .
Under transitional rules of the Tax Reform Act of 1986. Enter Act section ▶
Under the exception for current refunding (section 146(i) and section 1313(a) of the Tax Reform Act of 1986)
Amount of issue of qualified veterans’ mortgage bonds . . . . . . . . . . . . . . .
Enter the state limit on qualified veterans’ mortgage bonds . . . . . . . . . . . . .
Amount of section 1394(f) volume cap allocated to issuer. Attach copy of local government certification
Name of empowerment zone ▶
Amount of section 142(k)(5) volume cap allocated to issuer. Attach copy of state certification

Signature of issuer’s authorized representative

Print/Type preparer’s name

Preparer's signature

Date

▲

Paid
Preparer
Use Only

▲

Signature
and
Consent

52

Under penalties of perjury, I declare that I have examined this return, and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. I further declare that I consent to the IRS’s disclosure of the issuer’s return information, as necessary to process
this return, to the person(s) that I have authorized above.

Date

Type or print name and title
Check
if
self-employed

Firm’s name

▶

Firm's EIN

Firm's address

▶

Phone no.

Preparer's PTIN

▶

Form

8038 (Rev. 4-2011)