Form 8038-G Information Return for Tax-Exempt Governmental Obligatio

8038-G

Form
(Rev. September 2011)

Information Return for Tax-Exempt Governmental Obligations
▶ Under

Internal Revenue Code section 149(e)
▶ See separate instructions.
Caution: If the issue price is under $100,000, use Form 8038-GC.

Department of the Treasury
Internal Revenue Service

Part I
1

Reporting Authority

OMB No. 1545-0720

If Amended Return, check here
2

Issuer’s name

▶

Issuer’s employer identification number (EIN)

3a 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

4

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

5

Report number (For IRS Use Only)

6

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

7

Date of issue

8

Name of issue

9

CUSIP number

Room/suite

3

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

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

Part II
11
12
13
14
15
16
17
18
19
20

Type of Issue (enter the issue price). See the instructions and attach schedule.
Education . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health and hospital . . . . . . . . . . . . . . . . . . . . . . .
Transportation . . . . . . . . . . . . . . . . . . . . . . . . .
Public safety . . . . . . . . . . . . . . . . . . . . . . . . . .
Environment (including sewage bonds) . . . . . . . . . . . . . . . . .
Housing . . . . . . . . . . . . . . . . . . . . . . . . . . .
Utilities
. . . . . . . . . . . . . . . . . . . . . . . . . . .
Other. Describe ▶
If obligations are TANs or RANs, check only box 19a . . . . . . . . . . . .
If obligations are BANs, check only box 19b . . . . . . . . . . . . . . .
If obligations are in the form of a lease or installment sale, check box . . . . . . .

Part III

21
22
23
24
25
26
27
28
29
30

(c) Stated redemption
price at maturity

(b) Issue price

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11
12
13
14
15
16
17
18

▶
▶
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$

(d) Weighted
average maturity

$

(e) Yield

years

Uses of Proceeds of Bond Issue (including underwriters’ discount)

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
25
Proceeds used for credit enhancement . . . . . . . . . . . .
Proceeds allocated to reasonably required reserve or replacement fund .
26
27
Proceeds used to currently refund prior issues
. . . . . . . . .
Proceeds used to advance refund prior issues
. . . . . . . . .
28
Total (add lines 24 through 28) . . . . . . . . . . . . . . . . . . . .
Nonrefunding proceeds of the issue (subtract line 29 from line 23 and enter amount here)

Part V

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

Part IV

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22
23

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29
30

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

31
Enter the remaining weighted average maturity of the bonds to be currently refunded . . . .
32
Enter the remaining weighted average maturity of the bonds to be advance refunded . . . .
33
Enter the last date on which the refunded bonds will be called (MM/DD/YYYY) . . . . . .
34
Enter the date(s) the refunded bonds were issued ▶ (MM/DD/YYYY)
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 63773S

▶
▶

years
years

▶
Form 8038-G (Rev. 9-2011)

Page 2

Form 8038-G (Rev. 9-2011)

Part VI
35
36a

Miscellaneous
35

Enter the amount of the state volume cap allocated to the issue under section 141(b)(5) . . . .
Enter the amount of gross proceeds invested or to be invested in a guaranteed investment contract
(GIC) (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . .

36a

b Enter the final maturity date of the GIC ▶
c Enter the name of the GIC provider ▶
37
Pooled financings: Enter the amount of the proceeds of this issue that are to be used to make loans
to other governmental units . . . . . . . . . . . . . . . . . . . . . . . .
38a
b
c
d
39
40
41a
b
c
d
42
43

37
If this issue is a loan made from the proceeds of another tax-exempt issue, check box ▶
and enter the following information:
Enter the date of the master pool obligation ▶
Enter the EIN of the issuer of the master pool obligation ▶
Enter the name of the issuer of the master pool obligation ▶
▶
If the issuer has designated the issue under section 265(b)(3)(B)(i)(III) (small issuer exception), check box . . . .
▶
If the issuer has elected to pay a penalty in lieu of arbitrage rebate, check box . . . . . . . . . . . . .
▶
If the issuer has identified a hedge, check here
and enter the following information:
Name of hedge provider ▶
Type of hedge ▶
Term of hedge ▶
▶
If the issuer has superintegrated the hedge, check box . . . . . . . . . . . . . . . . . . . . .
If the issuer has established written procedures to ensure that all nonqualified bonds of this issue are remediated
▶
according to the requirements under the Code and Regulations (see instructions), check box . . . . . . . .

44
45a

If the issuer has established written procedures to monitor the requirements of section 148, check box . . .
If some portion of the proceeds was used to reimburse expenditures, check here ▶
and enter the amount
of reimbursement . . . . . . . . . ▶
b Enter the date the official intent was adopted ▶

▶

Signature of issuer’s authorized representative

Print/Type preparer’s name

Preparer's signature

Date

▲

Paid
Preparer
Use Only

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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 that I have authorized above.

▲

Signature
and
Consent

.

Type or print name and title
Date
PTIN
Check
if
self-employed

Firm’s name

▶

Firm's EIN

Firm's address

▶

Phone no.

▶

Form 8038-G (Rev. 9-2011)