Free Form 8038 (Rev. September 2007) - Federal

Form

8038
Reporting Authority

(Rev. September 2007)
Department of the Treasury Internal Revenue Service

Information Return for Tax-Exempt Private Activity Bond Issues
(Under Internal Revenue Code section 149(e)) See separate instructions.

OMB No. 1545-0720

Part I
1

Check if Amended Return
2 Issuer's employer identification number

Issuer's name

3

Number and street (or P.O. box if mail is not delivered to street address)

Room/suite

4

Report number

1
5 City, town, or post office, state, and ZIP code 6 Date of issue

7

Name of issue

8

CUSIP number Telephone number of officer or legal representative

9

Name and title of officer or legal representative whom the IRS may call for more information

10

(

) Issue Price

Part II
11 a b c d e f

Type of Issue (check the applicable box(es) and enter the issue price for each)

g h

i j k l m n o p q 12a b 13 14 15 16 17 18 19 20a b c

Exempt facility bond: 11a Airport (sections 142(a)(1) and 142(c)) 11b Docks and wharves (sections 142(a)(2) and 142(c)) 11c Water furnishing facilities (sections 142(a)(4) and 142(e)) 11d Sewage facilities (section 142(a)(5)) 11e Solid waste disposal facilities (section 142(a)(6)) 11f Qualified residential rental projects (sections 142(a)(7) and 142(d)), (see instructions) Meeting 20­50 test (section 142(d)(1)(A)) Meeting 40­60 test (section 142(d)(1)(B)) Meeting 25­60 test (NYC only) (section 142(d)(6)) Has an election been made for deep rent skewing (section 142(d)(4)(B))? Yes No 11g Facilities for the local furnishing of electric energy or gas (sections 142(a)(8) and 142(f)) 11h Facilities allowed under a transitional rule of the Tax Reform Act of 1986 (see instructions) Facility type 1986 Act section 11i Qualified enterprise zone facility bonds (section 1394) (see instructions) 11j Qualified empowerment zone facility bonds (section 1394(f)) (see instructions) 11k District of Columbia Enterprise Zone facility bonds (section 1400A) 11l Qualified public educational facility bonds (sections 142(a)(13) and 142(k)) 11m Qualified green building and sustainable design projects (sections 142(a)(14) and 142(l)) 11n Qualified highway or surface freight transfer facilities (sections 142(a)(15) and 142(m)) 11o Qualified Gulf Opportunity Zone Bonds (sections 1400N(a)(1)(A) and 1400N(a)(2)(A)(i)) 11p Qualified New York Liberty Bonds (section 1400L(d)) 11q Other. Describe (see instructions) 12a Qualified mortgage bond (section 143(a)) Qualified Gulf Opportunity Zone mortgage bond (sections 1400N(a)(1)(B) and 1400N(a)(2)(A)(ii)) 12b 13 Qualified veterans' mortgage bond (section 143(b)) (see instructions) Check the box if you elect to rebate arbitrage profits to the United States 14 Qualified small issue bond (section 144(a)) (see instructions) Check the box for $10 million small issue exemption 15 Qualified student loan bond (section 144(b)) 16 Qualified redevelopment bond (section 144(c)) 17 Qualified hospital bond (section 145(c)) (attach schedule--see instructions) 18 Qualified 501(c)(3) nonhospital bond (section 145(b)) (attach schedule--see instructions) Check box if 95% or more of net proceeds will be used only for capital expenditures 19 Nongovernmental output property bond (treated as private activity bond) (section 141(d)) 20a Gulf Opportunity Zone advance refunding bond (sections 1400N(b)(1)) (see instructions) 20b New York Liberty Zone advance refunding bond (section 1400L(e)) (see instructions) Other. Describe (see instructions) 20c

Part III

Description of Bonds (Complete for the entire issue for which this form is being filed.)
(b) Issue price (c) Stated redemption price at maturity (d) Weighted average maturity (e) Yield

(a) Final maturity date

21

$

$
Cat. No. 49973K

years
Form

%

For Paperwork Reduction Act Notice, see page 4 of the separate instructions.

8038

(Rev. 9-2007)

Form 8038 (Rev. 9-2007)

Page

2

Part IV
22 23 24 25 26 27 28 29 30

Uses of Proceeds of Issue (including underwriters' discount)
22 23

Amount

Proceeds used for accrued interest Issue price of entire issue (enter amount from line 21, column (b)) Proceeds used for bond issuance costs (including underwriters' discount) 24 25 Proceeds used for credit enhancement 26 Proceeds allocated to reasonably required reserve or replacement fund 27 Proceeds used to currently refund prior issue (complete Part VI) 28 Proceeds used to advance refund prior issue (complete Part VI) Add lines 24 through 28 Nonrefunding proceeds of the issue (subtract line 29 from line 23 and enter amount here)

29 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.

31 a b c d e 32 a b

Type of Property Financed by Nonrefunding Proceeds: 31a Land 31b Buildings and structures 31c Equipment with recovery period of more than 5 years 31d Equipment with recovery period of 5 years or less Other (describe) 31e North American Industry Classification System (NAICS) of the projects financed by nonrefunding proceeds.
NAICS Code Amount of nonrefunding proceeds NAICS Code

Amount

Amount of nonrefunding proceeds

$ $ Enter Enter Enter Enter the the the the

c d

$ $ years years

Part VI
33 34 35 36 37 38 39 40 41

Description of Refunded Bonds (Complete this part only for refunding bonds.)
remaining weighted average maturity of the bonds to be currently refunded remaining weighted average maturity of the bonds to be advance refunded last date on which the refunded bonds will be called date(s) the refunded bonds were issued

Part VII

Miscellaneous

Name of governmental unit(s) approving issue (see the instructions) Check the box if you have designated any issue under section 265(b)(3)(B)(i)(III) Check the box if you have elected to pay a penalty in lieu of arbitrage rebate Check the box if you have identified a hedge (see instructions) Check the box if the issue is comprised of qualified redevelopment, qualified small issue, or exempt facilities bonds and provide name and EIN of the primary private user Name EIN

Part VIII
42 43 44 a b c d 45a b 46a b 47

Volume Caps
42 43 44 44a 44b 44c 44d 45a 45b 46a 47

Amount

Amount of state volume cap allocated to the issuer. Attach copy of state certification Amount of issue subject to the unified state volume cap Amount of issue not subject to the unified state volume cap or other volume limitations: Of bonds for governmentally owned solid waste facilities, airports, docks, wharves, environmental enhancements of hydroelectric generating facilities, or high-speed intercity rail facilities Under a carryforward election. Attach a copy of Form 8328 to this return Under transitional rules of the Tax Reform Act of 1986. Enter Act section Under the exception for current refunding (section 146(i) and section 1313(a) of the Tax Reform Act of 1986) Amount of issue of qualified veterans' mortgage bonds Enter the state limit on qualified veterans' mortgage bonds Amount of section 1394(f) volume cap allocated to issuer. Attach copy of local government certification Name of empowerment zone Amount of section 142(k)(5) volume cap allocated to issuer. Attach copy of state certification

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.

Sign Here

Signature of officer

Date

Name of above officer (type or print)

Title of officer (type or print) Form

8038

(Rev. 9-2007)