8038-G Information Return for Tax-Exempt Governmental Bonds

Form

8038-G

Information Return for Tax-Exempt Governmental Bonds

(Rev. October 2021)
Department of the Treasury
Internal Revenue Service

Part I
1

Under Internal Revenue Code section 149(e)
▶ See separate instructions.
Caution: If the issue price is under $100,000, use Form 8038-GC.
▶ Go to www.irs.gov/F8038G for instructions and the latest information.
▶

Reporting Authority

OMB No. 1545-0047

Check box if Amended Return ▶
2

Issuer’s name

Issuer’s employer identification number (EIN)

3a Name of person (other than issuer) with whom the IRS may communicate about this return (see instructions)

3b Telephone number of other person shown on 3a

4

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

5

Report number (For IRS Use Only)

6

City, town, or post office, state, and ZIP code

7

Date of issue

8

Name of issue

9

CUSIP number

Room/suite

3

10a Name and title of officer or other employee of the issuer whom the IRS may call for more information

10b Telephone number of officer or other
employee shown on 10a

Part II
11
12
13
14
15
16
17
18
19a
b
20

Type of Issue (Enter the issue price.) See the instructions and attach schedule.
Education . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health and hospital . . . . . . . . . . . . . . . . . . . . . . .
Transportation . . . . . . . . . . . . . . . . . . . . . . . . .
Public safety . . . . . . . . . . . . . . . . . . . . . . . . . .
Environment (including sewage bonds) . . . . . . . . . . . . . . . . .
Housing . . . . . . . . . . . . . . . . . . . . . . . . . . .
Utilities
. . . . . . . . . . . . . . . . . . . . . . . . . . .
Other. Describe ▶
If bonds are TANs or RANs, check only box 19a . . . . . . . . . . . . . .
If bonds are BANs, check only box 19b . . . . . . . . . . . . . . . . .
If bonds are in the form of a lease or installment sale, check box
. . . . . . . .

Part III
21
22
23
24
25
26
27
28
29
30
31
32
33
34

(c) Stated redemption
price at maturity

(b) Issue price

$

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▶

11
12
13
14
15
16
17
18

▶
▶

(d) Weighted
average maturity

(e) Yield

years

$

%

Uses of Proceeds of Bond Issue (including underwriters’ discount)

Proceeds used for accrued interest . . . . . . . . . . . . . . . . . .
Issue price of entire issue (enter amount from line 21, column (b)) . . . . . . . .
Proceeds used for bond issuance costs (including underwriters’ discount)
24
Proceeds used for credit enhancement . . . . . . . . . . . .
25
Proceeds allocated to reasonably required reserve or replacement fund .
26
Proceeds used to refund prior tax-exempt bonds. Complete Part V . . .
27
Proceeds used to refund prior taxable bonds. Complete Part V . . . .
28
Total (add lines 24 through 28) . . . . . . . . . . . . . . . . . . . .
Nonrefunding proceeds of the issue (subtract line 29 from line 23 and enter amount here)

Part V

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Description of Bonds. Complete for the entire issue for which this form is being filed.
(a) Final maturity date

Part IV

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22
23

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29
30

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▶

Description of Refunded Bonds. Complete this part only for refunding bonds.

Enter the remaining weighted average maturity of the tax-exempt bonds to be refunded . .
Enter the remaining weighted average maturity of the taxable bonds to be refunded . . .
Enter the last date on which the refunded tax-exempt bonds will be called (MM/DD/YYYY) .
Enter the date(s) the refunded bonds were issued ▶ (MM/DD/YYYY)

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 63773S

▶

years
years

▶
Form 8038-G (Rev. 10-2021)

Page 2

Form 8038-G (Rev. 10-2021)

Part VI
35
36a
b
c
37
38a
b
c
d
39
40
41a
b
c
d
42
43
44
45a
b

Miscellaneous

Enter the amount of the state volume cap allocated to the issue under section 141(b)(5) . . . .
35
Enter the amount of gross proceeds invested or to be invested in a guaranteed investment contract
(GIC). See instructions . . . . . . . . . . . . . . . . . . . . . . . . .
36a
Enter the final maturity date of the GIC ▶ (MM/DD/YYYY)
Enter the name of the GIC provider ▶
Pooled financings: Enter the amount of the proceeds of this issue that are to be used to make loans
to other governmental units . . . . . . . . . . . . . . . . . . . . . . . .
37
If this issue is a loan made from the proceeds of another tax-exempt issue, check box ▶
and enter the following information:
Enter the date of the master pool bond ▶ (MM/DD/YYYY)
Enter the EIN of the issuer of the master pool bond ▶
Enter the name of the issuer of the master pool bond ▶
▶
If the issuer has designated the issue under section 265(b)(3)(B)(i)(III) (small issuer exception), check box . . . .
▶
If the issuer has elected to pay a penalty in lieu of arbitrage rebate, check box . . . . . . . . . . . . .
▶
If the issuer has identified a hedge, check here
and enter the following information:
Name of hedge provider ▶
Type of hedge ▶
Term of hedge ▶
▶
If the issuer has superintegrated the hedge, check box . . . . . . . . . . . . . . . . . . . . .
If the issuer has established written procedures to ensure that all nonqualified bonds of this issue are remediated
▶
according to the requirements under the Code and Regulations (see instructions), check box . . . . . . . .
▶
If the issuer has established written procedures to monitor the requirements of section 148, check box . . . . .
▶
If some portion of the proceeds was used to reimburse expenditures, check here
and enter the amount
of reimbursement . . . . . . . . . . . . . . ▶
Enter the date the official intent was adopted ▶ (MM/DD/YYYY)

Signature of issuer’s authorized representative

Print/Type preparer’s name

Preparer’s signature

Date

▲

Paid
Preparer
Use Only

▲

Signature
and
Consent

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.

Type or print name and title

Date

Check
if PTIN
self-employed

Firm’s name

▶

Firm’s EIN ▶

Firm’s address

▶

Phone no.
Form 8038-G (Rev. 10-2021)