8038-T Arbitrage Rebate, Yield Reduction and Penalty in Lieu of

Form

8038-T

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

(Rev. April 2011)

Part I

OMB No. 1545-1219

Under Sections 143(g)(3) and 148(f)
and Section 103(c)(6)(D) of the Internal Revenue Code of 1954
▶

Department of the Treasury
Internal Revenue Service

Reporting Authority

Check box if Amended Return ▶

1

Issuer’s name

2

Issuer’s employer identification number (EIN)

3

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

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

10

11

Type of issue ▶

Issue price ▶

12
13
14
15

Computation date to which this payment relates (MM/DD/YYYY) . . . . .
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) . .

Room/suite

7

Part II

Part III

11

Arbitrage Rebate and Yield Reduction Payments

Number of months since date of issue:

17
18
19

6 mos
12 mos
18 mos
Penalty in lieu of rebate . . . . . . .
Date of termination election (MM/DD/YYYY) .
Penalty upon termination
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24 mos
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Other. No. of mos ▶
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15

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17

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19

Late Payments

20

Does failure to pay timely qualify for waiver of penalty (see instructions) .

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21
22

Penalty for failure to pay on time (see instructions)
Interest on underpayment (see instructions) . .

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21
22

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

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23

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24

Part V
23

Part VI

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Yes

No

Total Payment
Miscellaneous

24

Unspent proceeds as of this computation date

25
26

Proceeds used to redeem bonds . . . . . . . . . . . . . . . . . . . . .
Gross proceeds used for qualified administrative costs for guaranteed investment contracts (GICs) and
defeasance escrows . . . . . . . . . . . . . . . . . . . . . . . . .

25

27

Fees paid for a qualified guarantee .

27

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Amount

13
14

Penalty in Lieu of Arbitrage Rebate

16

Part IV

Telephone number of officer or other person

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26

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Yes
28
29

Is the issue a variable rate issue? .
Did the issuer enter into a hedge?

30

Were gross proceeds invested in a GIC?

31
32

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

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Name of provider

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28

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Term of hedge
Name of provider
Term of GIC

29
30

Signature of issuer’s authorized representative

Print/Type preparer’s name

Date

Preparer's signature

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Paid
Preparer
Use Only

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31

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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. 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
and
Consent

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No

Type or print name and title
Date

Check
if
self-employed

Firm’s name

▶

Firm's EIN

Firm's address

▶

Phone no.

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 11545Y

PTIN

▶

Form 8038-T (Rev. 4-2011)