Form Schedule K (Form 9 Schedule K (Form 9 Supplemental Information on Tax Exempt Bonds

SCHEDULE K
(Form 990)

OMB No. 1545-0047

Supplemental Information on Tax-Exempt Bonds
©

2009

Complete if the organization answered “Yes” to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information on Schedule O (Form 990).

Department of the Treasury
Internal Revenue Service

©

Open to Public
Inspection

Attach to Form 990. See separate instructions.

Name of the organization

Part I

Employer identification number

Bond Issues
(a) Issuer name

(c) CUSIP #

(b) Issuer EIN

(d) Date issued

(f) Description of purpose

(e) Issue price

(g) Defeased

(h) On
behalf of
issuer

Yes No Yes No

A
B
C
D
E

Part II

Proceeds
B

A
1
2
3
4
5
6
7
8

Total proceeds of issue
Gross proceeds in reserve funds
Proceeds in refunding or defeasance escrows
Other unspent proceeds
Issuance costs from proceeds
Working capital expenditures from proceeds
Capital expenditures from proceeds
Year of substantial completion

9

Were the bonds issued as part of a current refunding issue?

Yes

10
11
12

No

Yes

No

Yes

C

No

Yes

No

Yes

E

D

No

Yes

No

Yes

No

Yes

No

Yes

No

Were the bonds issued as part of an advance
refunding issue?
Has the final allocation of proceeds been made?
Does the organization maintain adequate books and
records to support the final allocation of proceeds?

Part III

Private Business Use
B

A
1

Was the organization a partner in a partnership, or a
member of an LLC, which owned property financed by
tax-exempt bonds?

2

Are there any lease arrangements with respect to the
financed property which may result in private business use?

Yes

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

C

E

D

Cat. No. 50193E

No

Schedule K (Form 990) 2009

Schedule K (Form 990) 2009

Part III

Page

2

Private Business Use (Continued)
B

A
Yes

3a Are there any management or service contracts with
respect to the financed property which may result in
private business use?

No

Yes

C
No

Yes

E

D
No

Yes

No

Yes

No

b Are there any research agreements with respect to the
financed property which may result in private business
use?
c Does the organization routinely engage bond counsel
or other outside counsel to review any management or
service contracts or research agreements relating to
the financed property?
4

Enter the percentage of financed property used in a
private business use by entities other than a section
501(c)(3) organization or a state or local government

©

5

Enter the percentage of financed property used in a private
business use as a result of unrelated trade or business
activity carried on by your organization, another section
©
501(c)(3) organization, or a state or local government

6

Total of lines 4 and 5

7

Has the organization adopted management practices
and procedures to ensure the post-issuance
compliance of its tax-exempt bond liabilities?

Part IV

%

%

%

%

%

%
%

%
%

%
%

%
%

%
%

Arbitrage
B

A
1

Has a Form 8038-T, Arbitrage Rebate, Yield Reduction
and Penalty in Lieu of Arbitrage Rebate, been filed
with respect to the bond issue?

2

Is the bond issue a variable rate issue?

Yes

No

Yes

C
No

Yes

E

D
No

Yes

No

Yes

No

3a Has the organization or the governmental issuer
identified a hedge with respect to the bond issue on
its books and records?
b Name of provider
c Term of hedge
4a Were gross proceeds invested in a GIC?
b Name of provider
c Term of GIC
d Was the regulatory safe harbor for establishing the fair
market value of the GIC satisfied?
5

Were any gross proceeds invested beyond an
available temporary period?

6

Did the bond issue qualify for an exception to rebate?
Schedule K (Form 990) 2009