8038-T (2017 Draft Arbitrage Rebate, Yield Reduction and Penalty in Lieu of

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DRAFT AS OF
April 13, 2017
DO NOT FILE

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Form

8038-T

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

(Rev. September 2017)
Department of the Treasury
Internal Revenue Service

Part I

▶

OMB No. 1545-0720

Under sections 143(g)(3) and 148(f) and section 103(c)(6)(D) of the Internal Revenue Code of 1954
▶ Go to www.irs.gov/Form8038t for instructions and the latest information.

Reporting Authority

Check box if Amended Return ▶

1

Issuer’s name

2

3

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

5

Issuer’s employer identification number (EIN)

DRAFT AS OF
April 13, 2017
DO NOT FILE
4

Report number (For IRS Use Only)

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) . . . . .
check box if less than 100% of rebate amount . . .
Arbitrage rebate payment (see instructions)
check box if less than 100% of yield reduction amount .
Yield reduction payment (see instructions)

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13
14

Rebate payment from Qualified Zone Academy Bond (QZAB) defeasance escrow (see instructions) .

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Room/suite

7

Part II

Part III
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17
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19

Telephone number of officer or other person

11

▶

Arbitrage Rebate and Yield Reduction Payments

Penalty in Lieu of Arbitrage Rebate

Number of months since date of issue:
6 mos
12 mos
18 mos

24 mos

No. of mos ▶

Other
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17

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Does failure to pay timely qualify for waiver of penalty? See instructions .

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

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

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23

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Penalty in lieu of rebate . . . . . . .
Date of termination election (MM/DD/YYYY) .
Penalty upon termination
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Part IV

Part V
23

Part VI

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Late Payments
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Yes

No

Total Payment
Miscellaneous

24

Unspent proceeds as of this computation date

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24

25
26

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

25
26

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Fees paid for a qualified guarantee .

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

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Were gross proceeds invested in a GIC?

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

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Amount

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Name of provider

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Yes
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No

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

Firm’s name

▶

Firm’s address

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Date

Preparer’s signature

For Paperwork Reduction Act Notice, see the separate instructions.

▲

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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Type or print name and title
Date

Check
if
self-employed
Firm’s EIN

PTIN

▶

Phone no.
Cat. No. 11545Y

Form 8038-T (Rev. 9-2017)