Request for Recovery of Overpayments Under Arbitrage Rebate Provisions

August

Version A, Cycle 1

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Form

Request for Recovery of Overpayments
Under Arbitrage Rebate Provisions

8038-R

(Rev. April 2010)
Department of the Treasury
Internal Revenue Service

Part I





File a separate form for each issue.

OMB No. 1545-1750

italics

See instructions.

Reporting Authority
2 Issuer’s employer identification number (EIN)

1 Issuer’s name

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

Room/suite

4 Report number (For IRS Use Only)

5 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 of the issuer or other person whom the IRS may call for more information

Part II

10 Telephone number of officer or other person

Request for Refund of Amounts Paid Under Rebate Provisions (see instructions)

11

If the issue is outstanding on June 30, 1993, and the issuer elects not to apply the 1992 regulations, check here (see
instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

12

Total amount paid under rebate provisions .

13
14

Rebate amount as of the most recent computation date . . . . .
Amounts (not included in line 12) required to be paid under section 148
as of the date the recovery is requested . . . . . . . . . . .

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12

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DRAFT AS OF
April 21, 2010
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15

Add lines 13 and 14

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16
Amount of overpayment. Subtract line 15 from line 12 . . . . . . . . . . . . . . .
Computations and relevant facts that led to overpayment (see instructions). Attach additional sheets if necessary.

18

Schedule of payments (see instructions). Attach additional sheets if necessary.

Part III

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Other Information (see instructions)

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15

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Check the “Yes” or “No” box for each question below.

19

Was the overpayment paid as penalty in lieu of rebate under section 148(f)(4)(C)(vii)?

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21

Has the final computation date for the issue occurred? . . . . . . . . . . . . . . . . . . 
Is the issue comprised of qualified redevelopment, qualified small issue, or exempt facilities bonds? If “Yes,”
INSERT A
provide name and EIN of the primary private user.

20

Name

Signature
and
Consent

Paid
Preparer’s
Use Only



EIN

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Yes

No

21

Under penalties of perjury, I declare that I have examined this request for recovery of overpayment, including accompanying schedules and statements, and
to the best of my knowledge and belief, the facts represented in support of the request 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.



Signature of issuer’s authorized representative



Preparer’s
signature
Firm's name (or yours
if self-employed),
address, and ZIP code



Date
Date

Type or print name and title
Preparer's SSN or PTIN
Check if selfemployed 



For Privacy Act and Paperwork Reduction Act Notice, see page 3.

EIN 
Phone no.
Cat. No. 57334H

INSERT B

Form

8038-R (Rev. 4-2010)
8

INSERT A
If an entity other than a governmental entity is to use proceeds of these obligations, enter the
name and EIN of that organization. If more than one, attach schedule.
INSERT B
22. If the issuer wishes to authorize the IRS to communicate directly with a person who is a
representative of the entity listed on line 21, check the box and enter the name and telephone
number of such person. (insert checkbox)
Name (dingbat)________________________ Phone no._________________________