Form 8038-G - Information Return For Tax-Exempt Governmental Obligations

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8038-G
Information Return for Tax-Exempt Governmental Obligations
Form
Under Internal Revenue Code section 149(e)
▶
(Rev. September 2011)
OMB No. 1545-0720
See separate instructions.
▶
Department of the Treasury
Caution: If the issue price is under $100,000, use Form 8038-GC.
Internal Revenue Service
Part I
Reporting Authority
If Amended Return, check here
▶
1 Issuer’s name
2 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)
Room/suite
3
6 City, town, or post office, state, and ZIP code
7 Date of issue
8 Name of issue
9 CUSIP number
10a Name and title of officer or other employee of the issuer whom the IRS may call for more information (see
10b Telephone number of officer or other
instructions)
employee shown on 10a
Part II
Type of Issue (enter the issue price).
See the instructions and attach schedule.
11
Education .
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Health and hospital
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Transportation .
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Public safety .
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Environment (including sewage bonds) .
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Housing
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Utilities
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18
Other. Describe
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19
If obligations are TANs or RANs, check only box 19a
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If obligations are BANs, check only box 19b
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20
If obligations are in the form of a lease or installment sale, check box .
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Part III
Description of Obligations. Complete for the entire issue for which this form is being filed.
(c) Stated redemption
(d) Weighted
(a) Final maturity date
(b) Issue price
(e) Yield
price at maturity
average maturity
21
$
$
years
%
Part IV
Uses of Proceeds of Bond Issue (including underwriters’ discount)
22
Proceeds used for accrued interest
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22
23
Issue price of entire issue (enter amount from line 21, column (b))
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23
24
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Proceeds used for bond issuance costs (including underwriters’ discount) .
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Proceeds used for credit enhancement .
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Proceeds allocated to reasonably required reserve or replacement fund .
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Proceeds used to currently refund prior issues
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28
Proceeds used to advance refund prior issues
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Total (add lines 24 through 28) .
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29
30
Nonrefunding proceeds of the issue (subtract line 29 from line 23 and enter amount here)
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30
Part V
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 .
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years
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32
Enter the remaining weighted average maturity of the bonds to be advance refunded .
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years
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33
Enter the last date on which the refunded bonds will be called (MM/DD/YYYY) .
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34
Enter the date(s) the refunded bonds were issued
▶ (MM/DD/YYYY)
8038-G
For Paperwork Reduction Act Notice, see separate instructions.
Form
(Rev. 9-2011)
Cat. No. 63773S

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