Form 8038 - Information Return For Tax-Exempt Private Activity Bond Issues Page 2
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Form 8038 (Rev. 4-2011)
Page
Part III
Description of Bonds (Complete for the entire issue for which this form is being filed.)
(a) Final maturity date
(b) Issue price
(c) Stated redemption
(d) Weighted
(e) Yield
price at maturity
average maturity
21
years
$
$
%
Part IV
Uses of Proceeds of Issue (including underwriters’ discount)
Amount
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
24
Proceeds used for bond issuance costs (including underwriters’ discount)
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Proceeds used for credit enhancement .
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25
26
Proceeds allocated to reasonably required reserve or replacement fund .
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27
27
Proceeds used to currently refund prior issue (complete Part VI) .
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28
Proceeds used to advance refund prior issue (complete Part VI) .
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28
29
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 Property Financed by Nonrefunding Proceeds
Caution: The total of lines 31a through e below must equal line 30 above. Do not complete for qualified student loan
bonds, qualified mortgage bonds, or qualified veterans’ mortgage bonds.
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Type of Property Financed by Nonrefunding Proceeds:
Amount
a Land
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31a
b Buildings and structures .
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31b
c Equipment with recovery period of more than 5 years
31c
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d Equipment with recovery period of 5 years or less
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31d
e Other. Describe (see instructions)
31e
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North American Industry Classification System (NAICS) of the projects financed by nonrefunding proceeds.
NAICS Code
Amount of nonrefunding proceeds
NAICS Code
Amount of nonrefunding proceeds
a
c
$
$
b
d
$
$
Part VI
Description of Refunded Bonds (Complete this part only for refunding bonds.)
years
33
Enter the remaining weighted average maturity of the bonds to be currently refunded .
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years
34
Enter the remaining weighted average maturity of the bonds to be advance refunded .
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Enter the last date on which the refunded bonds will be called
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36
Enter the date(s) the refunded bonds were issued
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Part VII
Miscellaneous
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Name of governmental unit(s) approving issue (see the instructions)
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Check the box if you have designated any issue under section 265(b)(3)(B)(i)(III) .
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Check the box if you have elected to pay a penalty in lieu of arbitrage rebate
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40 a Check the box if you have identified a hedge and enter the following information
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b Name of hedge provider
c Type of hedge
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d Term of hedge
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Check the box if the hedge is superintegrated .
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42 a Enter the amount of gross proceeds invested or to be invested in a guaranteed investment contract (GIC)
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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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Check the box if the issuer has established written procedures to ensure that all nonqualified bonds of this issue are
remediated in accordance with the requirements under the Code and Regulations (see instructions) .
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Check the box if the issuer has established written procedures to monitor the requirements of section 148
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45a Enter the amount of reimbursement if some portion of the proceeds was used to reimburse expenditures .
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b Enter the date the official intent was adopted .
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Check the box if the issue is comprised of qualified redevelopment, qualified small issue, or exempt facilities bonds and
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provide name and EIN of the primary private user
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Name
EIN
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8038
Form
(Rev. 4-2011)
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