Form 8038-G - Information Return For Tax-Exempt Governmental Obligations Page 2

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Form 8038-G (Rev. 9-2011)

Page

Part VI

Miscellaneous

Enter the amount of the state volume cap allocated to the issue under section 141(b)(5) .

36 a 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

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c Enter the name of the GIC provider

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Pooled financings: Enter the amount of the proceeds of this issue that are to be used to make loans

to other governmental units .

38 a If this issue is a loan made from the proceeds of another tax-exempt issue, check box

and enter the following information:

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b Enter the date of the master pool obligation

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c Enter the EIN of the issuer of the master pool obligation

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d Enter the name of the issuer of the master pool obligation

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If the issuer has designated the issue under section 265(b)(3)(B)(i)(III) (small issuer exception), check box

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If the issuer has elected to pay a penalty in lieu of arbitrage rebate, check box .

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41 a If the issuer has identified a hedge, check here

and enter the following information:

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b Name of hedge provider

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c Type of hedge

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d Term of hedge

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If the issuer has superintegrated the hedge, check box .

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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 .

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If the issuer has established written procedures to monitor the requirements of section 148, check box .

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45a If some portion of the proceeds was used to reimburse expenditures, check here

and enter the amount

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of reimbursement .

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b Enter the date the official intent was adopted

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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

Signature

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.

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