Form 8038-T Arbitrage Rebate and Penalty in Lieu of Arbitrage Rebate

Form

8038-T

Arbitrage Rebate, Yield Reduction
and Penalty in Lieu of Arbitrage Rebate

(Rev. January 2005)

Part I

OMB No. 1545-1219

䊳

Department of the Treasury
Internal Revenue Service

Reporting

Under Sections 143(g)(3) and 148(f)
and Sections 103(c)(6)(D) and 103A(i)(4) of the Internal Revenue Code of 1954
Check box if Amended Return
Authority

1

Issuer’s name

3

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

5

䊳

2

Issuer’s employer identification number

4

Report number

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

6

Date of issue

7

Name of issue

8

CUSIP number

9

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

10

Telephone number of officer or legal representative

Room/suite

7

(
䊳

)
䊳

11

$

13

$

14

$

15

$

17

$

19

$

21
22

$
$

23

$

Unspent proceeds as of this computation date

24

25

Proceeds used to redeem bonds

25

26

Gross proceeds used for qualified administrative costs for GICs and defeasance escrows

26

$
$
$

27

Fees paid for a qualified guarantee

27

$

11

Type of issue

Part II

Issue price

Arbitrage Rebate and Yield Reduction Payments

12

Computation date to which this payment relates (MMDDYYYY)

13
14
15

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
16

Penalty in Lieu of Arbitrage Rebate

Number of months since date of issue:
6 mos

17
18
19

Late Payments
Yes

No

Total Payment

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

Part VI
24

Other. No. of mos 䊳

24 mos

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
23

18 mos

Penalty in lieu of rebate
Date of termination election (MMDDYYYY)
Penalty upon termination

Part IV
20
21
22

12 mos

Miscellaneous

Yes
28

Is the issue a variable rate issue?

29

Did the issuer enter into a hedge?

No

28
Name of provider
29

Term of hedge
30

Were gross proceeds invested in a GIC? Name of provider

31
32

Term of GIC
Were any gross proceeds invested beyond an available temporary period?
Calculations for filing of this form prepared by:
Issuer

30
31
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.

Sign
Here

䊳

䊳
Signature of issuer’s authorized representative

For Paperwork Reduction Act Notice, see the separate instructions.

Date

Type or print name and title
Cat. No. 11545Y

Form

8038-T

(Rev. 1-2005)