Form 8038-R - Request For Recovery Of Overpayments Under Arbitrage Rebate Provisions Form

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8038-R
Request for Recovery of Overpayments
Form
Under Arbitrage Rebate Provisions
OMB No. 1545-1750
(Rev. April 2011)
Department of the Treasury
File a separate form for each issue.
See instructions.
Internal Revenue Service
Part I
Reporting Authority
1 Issuer’s name
2 Issuer’s employer identification number (EIN)
3 Number and street (or P.O. box if mail is not delivered to street address)
Room/suite
4 Report number (For IRS Use Only)
5 City, town, or post office, state, and ZIP code
6 Date of issue
7 Name of issue
8 CUSIP number
9 Name and title of officer of the issuer or other person whom the IRS may call for more information
10 Telephone number of officer or other person
Part II
Request for Refund of Amounts Paid Under Rebate Provisions (see instructions)
If the issue was outstanding on or prior to June 30, 1993, and the issuer elects not to apply the 1992 regulations, check
11
here (see instructions)
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12
12
Total amount paid under rebate provisions .
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13
Rebate amount as of the most recent computation date
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13
14
Amounts (not included in line 12) required to be paid under section 148
as of the date the recovery is requested .
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14
15
Add lines 13 and 14
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15
16
Amount of overpayment. Subtract line 15 from line 12 .
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16
17
Computations and relevant facts that led to overpayment (see instructions). Attach additional sheets if necessary.
18
Schedule of payments (see instructions). Attach additional sheets if necessary.
Part III
Other Information (see instructions)
Yes
No
Check the “Yes” or “No” box for each question below.
19
Was the overpayment paid as penalty in lieu of rebate under section 148(f)(4)(C)(vii)? .
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19
20
Has the final computation date for the issue occurred? .
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20
21
If an entity other than a governmental entity is to use proceeds of these obligations, enter the name and EIN of that
organization. If more than one, attach schedule.
Name
EIN
22
If the issuer wishes to authorize the IRS to communicate directly with a person who is a representative of the entity listed on
line 21, check the box and enter the name and telephone number of such person.
Name
Phone no.
Under penalties of perjury, I declare that I have examined this request for recovery of overpayment, including accompanying schedules and statements, and
to the best of my knowledge and belief, the facts represented in support of the request are true, correct, and complete. I further declare that I consent to the
Signature
IRS's disclosure of the issuer's return information, as necessary to process this return, to the persons that I have authorized on lines 9 and 22 above.
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
if
self-employed
Preparer
Use Only
Firm’s name
Firm's EIN
Firm's address
Phone no.
8038-R
For Paperwork Reduction Act Notice, see the instructions.
Form
(Rev. 4-2011)
Cat. No. 57334H

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