Form 8038-T - Arbitrage Rebate, Yield Reduction And Penalty In Lieu Of Arbitrage Rebate

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8038-T

Arbitrage Rebate, Yield Reduction

Form

and Penalty in Lieu of Arbitrage Rebate

(Rev. April 2011)

OMB No. 1545-1219

Under Sections 143(g)(3) and 148(f)

▶

Department of the Treasury

and Section 103(c)(6)(D) of the Internal Revenue Code of 1954

Internal Revenue Service

Part I

Reporting Authority

Check box if Amended Return

▶

Issuer’s employer identification number (EIN)

Issuer’s name

Number and street (or P.O. box no. if mail is not delivered to street address)

Room/suite

Report number (For IRS Use Only)

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

Date of issue

Name of issue

CUSIP number

Name and title of officer of the issuer or other person whom the IRS may call for more information

Telephone number of officer or other person

Issue price

Type of issue

▶

Part II

Arbitrage Rebate and Yield Reduction Payments

Amount

Computation date to which this payment relates (MM/DD/YYYY) .

Arbitrage rebate payment (see instructions)

check box if less than 100% of rebate amount .

Yield reduction payment (see instructions)

check box if less than 100% of yield reduction amount

Rebate payment from Qualified Zone Academy Bond (QZAB) defeasance escrow (see instructions) .

Part III

Penalty in Lieu of Arbitrage Rebate

Number of months since date of issue:

6 mos

12 mos

18 mos

24 mos

Other. No. of mos

▶

Penalty in lieu of rebate .

Date of termination election (MM/DD/YYYY) .

Penalty upon termination

Part IV

Late Payments

Yes

Does failure to pay timely qualify for waiver of penalty (see instructions) .

Penalty for failure to pay on time (see instructions)

Interest on underpayment (see instructions)

Part V

Total Payment

Total payment. Add lines 13, 14, 15, 17, 19, 21, and 22. Enter total here

Part VI

Miscellaneous

Unspent proceeds as of this computation date

Proceeds used to redeem bonds

Gross proceeds used for qualified administrative costs for guaranteed investment contracts (GICs) and

defeasance escrows .

Fees paid for a qualified guarantee .

Yes

Is the issue a variable rate issue?

Name of provider

Did the issuer enter into a hedge?

Term of hedge

Name of provider

Were gross proceeds invested in a GIC?

Term of GIC

Were any gross proceeds invested beyond an available temporary period? .

Calculations for filing of this form prepared by:

Issuer

Preparer:

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

Signature

process this return, to the person that I have authorized above.

and

Consent

Type or print name and title

Signature of issuer’s authorized representative

Date

Print/Type preparer’s name

Preparer's signature

Date

PTIN

Paid