Form 8038-Tc - Information Return For Tax Credit Bonds (Page 2 of 5) in pdf

Form 8038-TC (Rev. 11-2012)

Page

Description of Use of Proceeds for Qualified Purpose Expenditures (Continued)

Developing course materials and/or staff training expenditures .

Pay principal, interest, or premiums on qualified bonds .

Refinance a qualified indebtedness

Other (describe)

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Total qualified purpose expenditures (Sum of lines 1a through 13) .

Percentage of total proceeds to be used for qualified purpose expenditures (Divide line

14 in Part V by line 7 in Part IV, multiply result by 100) .

If some portion of proceeds was used to reimburse issuer for amounts paid for a qualified

purpose, enter the amount of reimbursement .

If some portion of proceeds was to reimburse issuer for amounts paid for a qualified purpose,

enter the date the official intent was adopted (MM/DD/YYYY)

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Allocation of National, State, Tribal, or Local Bond Limitation Amount

Part VI

(Enter source and amount of allocation and attach copy of certificate)

Amount

1 a Volume cap allocation amount .

Year of Allocation .

Amount of Carryforward .

b National, check box

Local, check box

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c State, check box

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d Tribal, check box

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If box 1c is checked, enter State abbreviation .

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Part VII

Miscellaneous

Arbitrage questions:

a If there is a reserve or sinking fund that is expected to repay the issue at maturity, check box .

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b If 1a is checked and the reserve or sinking fund is funded in equal periodic installments, check box .

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c If either the funding of the reserve or sinking fund is expected to result in an amount greater than the amount necessary

to repay the issue; or, if the yield on such fund is greater than the permitted sinking fund yield from line 6, Part III, check

box .

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d If the issuer established written procedures to monitor the requirements of section 148 with respect to these bonds,

check box

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If all federal, state, and local requirements governing conflicts of interest are satisfied with respect to this issue, check box .

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If the entitlements to credits with respect to this bond issue are expected to be stripped, check box .

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If the issuer established written procedures to ensure that all nonqualified bonds at the end of the applicable period are

redeemed within 90 days, check box .

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Other: .

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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(s) that I have authorized above.

Signature

and

Consent

Signature of issuer's authorized representative

Date

Type or print name and title

Print/Type preparer’s name

Preparer's signature

Date

PTIN

Paid

Check

self-employed

Preparer

Use Only

Firm’s name

Firm's EIN

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Firm's address

Phone no.

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Part VIII

Consent to Disclosure of Certain Information From This Return

Does the issuer give the IRS consent to publish, through a website or in a publication, its name and address, employer

identification number, name and description of bond issue, date of issuance, CUSIP number, issue price, final maturity date, stated

redemption price at maturity, applicable credit rate, and maximum term, to assist in the proper reporting of interest, tax credits, or

other benefits under IRC section 6049 and Regulations thereunder

▶

Yes

Under penalties of perjury, I declare that I am an officer of the above named issuer and that I am authorized to give consent on behalf of the above named issuer for the IRS

to publish the items of information described in line 1 of Part VIII of this form to assist in the reporting obligations under IRC section 6049.

Sign

Here

Date

Type or print name and title

Signature

8038-TC

Form

(Rev. 11-2012)