Form 8038-T Arbitrage Rebate and Penalty in Lieu of Arbitrage Rebate

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Date

Form

8038-T

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

(Rev. January 2005)

Signature

OMB No. 1545-1219

䊳

Department of the Treasury
Internal Revenue Service

Part I

Date

Reporting

Under Sections 143(g)(3) and 148(f)
and Sections 103(c)(6)(D) and 103A(i)(4) of the Internal Revenue Code of 1954
Check box if Amended Return
Authority

Issuer’s name

3

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

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 or legal representative whom the IRS may call for more information

10

Telephone number of officer or legal representative

Room/suite

2

Issuer’s employer identification number

4

Report number

䊳

1

7

(
11

Type of issue

Part II

䊳

)

Issue price

Computation date to which this payment relates (MMDDYYYY)

13
14
15

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)
Number of months since date of issue:

17
18
19

Penalty in lieu of rebate
Date of termination election (MMDDYYYY)
Penalty upon termination

6 mos

20
21
22

12 mos

18 mos

$

14

$

15

$

17

$

19

$

21
22

$
$

23

$

Late Payments
Yes

No

Total Payment

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

Part VI

13

Other. No. of mos 䊳

24 mos

Does failure to pay timely qualify for waiver of penalty (see instructions)
Penalty for failure to pay on time (see instructions)
Interest on underpayment (see instructions)

Part V
23

$

Penalty in Lieu of Arbitrage Rebate

16

Part IV

11

Arbitrage Rebate and Yield Reduction Payments

12

Part III

䊳

Miscellaneous

26

Gross proceeds used for qualified administrative costs for GICs and defeasance escrows

26

$
$
$

27

Fees paid for a qualified guarantee

27

$

28

Is the issue a variable rate issue?

29

Did the issuer enter into a hedge?

30

Were gross proceeds invested in a GIC? Name of provider

31
32

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

24

Unspent proceeds as of this computation date

24

25

Proceeds used to redeem bonds

25

Yes

No

28
Name of provider
29

Term of hedge

30
31
Preparer:

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.

Sign
Here

䊳

䊳
Signature of issuer’s authorized representative

For Paperwork Reduction Act Notice, see the separate instructions.

Date

Type or print name and title
Cat. No. 11545Y

Form

8038-T

(Rev. 1-2005)