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

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SCHEDULE K
(Form 990)

DRAFT AS OF
November 20, 2012
DO NOT FILE
Supplemental Information on Tax-Exempt Bonds

▶ Complete

Department of the Treasury
Internal Revenue Service

▶ Attach

Name of the organization

Part I

if the organization answered “Yes” to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
to Form 990.

▶ See

separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Employer identification number

Bond Issues

(a) Issuer name

(b) Issuer EIN

(c) CUSIP #

(d) Date issued

(e) Issue price

(f) Description of purpose

(g) Defeased

(h) On
behalf of
issuer

(i) Pooled
financing

Yes No Yes No Yes No

A
B
C
D

Part II

Proceeds
A

1
2
3
4
5
6
7
8
9
10
11
12
13

Amount of bonds retired . . . . . . .
Amount of bonds legally defeased
. . .
Total proceeds of issue . . . . . . .
Gross proceeds in reserve funds . . . .
Capitalized interest from proceeds . . .
Proceeds in refunding escrows . . . . .
Issuance costs from proceeds . . . . .
Credit enhancement from proceeds . . .
Working capital expenditures from proceeds
Capital expenditures from proceeds . . .
Other spent proceeds . . . . . . . .
Other unspent proceeds . . . . . . .
Year of substantial completion . . . . .

14
15
16
17

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

Part III

B

No

Yes

2

D

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Private Business Use
A

1

C

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Was the organization a partner in a partnership, or a member of an LLC,
which owned property financed by tax-exempt bonds? . . . . . . . .
Are there any lease arrangements that may result in private business use of
bond-financed property? . . . . . . . . . . . . . . . . . .

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

Yes

B

Cat. No. 50193E

C

D
No

Schedule K (Form 990) 2012

DRAFT AS OF
November 20, 2012
DO NOT FILE

Page 2

Schedule K (Form 990) 2012

Part III

Private Business Use (Continued)

A

3a

Are there any management or service contracts that may result in private
business use of bond-financed property? . . . . . . . . . . . .

Yes

B

No

Yes

C

No

Yes

No

D
Yes

No

b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside
counsel to review any management or service contracts relating to the financed property?
c

Are there any research agreements that may result in private business use of
bond-financed property? . . . . . . . . . . . . . . . . . .

d If "Yes" to line 3c, does the organization routinely engage bond counsel or other
outside counsel to review any 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 . . . ▶
Total of lines 4 and 5 . . . . . . . . . . . . . . . . . . .
Does the bond issue meet the private security or payment test? . . . . .

6
7
8a
b
c
9

Has there been a sale or disposition of any of the bond-financed property to a
nongovernmental person other than a 501(c)(3) organization since the bonds were issued?
If “Yes” to line 8a, enter the percentage of bond-financed property sold or
disposed of . . . . . . . . . . . . . . . . . . . . . .
If “Yes” to line 8a, was any remedial action taken pursuant to Regulations
sections 1.141-12 and 1.145-2? . . . . . . . . . . . . . .

.

Has the organization established written procedures to ensure that all
nonqualified bonds of the issue are remediated in accordance with the
requirements under Regulations sections 1.141-12 and 1.145-2? . .

.

Part IV

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%

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%

Arbitrage
A
Yes

1
2

Has the issuer filed Form 8038-T? . . .
If "No" to line 1, did the following apply?
a Rebate not due yet? . . . . . . .
b Exception to rebate? . . . . . . .
c No rebate due? . . . . . . . . .

3
4a

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B
No

Yes

C
No

Yes

D
No

Yes

No

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If you checked "No rebate due" in line 2c, provide in Part VI the date the
rebate computation was performed . . . . . . . . . . . . . .
Is the bond issue a variable rate issue? . . . . . . . . . . . . .

Has the organization or the governmental issuer entered
hedge with respect to the bond issue? . . . . . . .
b Name of provider . . . . . . . . . . . . . .
c Term of hedge . . . . . . . . . . . . . . .
d Was the hedge superintegrated? . . . . . . . . .
e Was the hedge terminated? . . . . . . . . . . .

into
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a qualified
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Schedule K (Form 990) 2012

DRAFT AS OF
November 20, 2012
DO NOT FILE

Page 3

Schedule K (Form 990) 2012

Part IV

Arbitrage (Continued)

A

Yes

5a
b
c
d
6
7

B

No

Yes

No

Yes

C

No

Yes

No

Yes

D

No

Yes

No

Yes

No

Were gross proceeds invested in a guaranteed investment contract (GIC)? .
Name of provider . . . . . . . . . . . . . . . . . . . .
Term of GIC . . . . . . . . . . . . . . . . . . . . . .
Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied?
Were any gross proceeds invested beyond an available temporary period? .
Has the organization established written procedures to monitor the
requirements of section 148? . . . . . . . . . . . . . . . .

Part V

Procedures To Undertake Corrective Action

A

Has the organization established written procedures to ensure that violations
of federal tax requirements are timely identified and corrected through the
voluntary closing agreement program if self-remediation is not available
under applicable regulations?

Part VI

Yes

B

C

D
No

Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions).

Schedule K (Form 990) 2012

DRAFT AS OF
November 20, 2012
DO NOT FILE

Page 4
Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions) (Continued)

Schedule K (Form 990) 2012

Part VI

Schedule K (Form 990) 2012