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Form 0 V - (Rev. January 2012) Department of the Treasury internal Revenue Service Information Return for Small Tax -Exempt Governmental Band Issues, Leases, and Installment Sales ► Under Internal Revenue Code section 149(e) Caution: if the issue price of the issue is $100.000 ormore, use Form 8038-G. oMe No. 1545-0720 1 Issuer's name i 2 Issuer's employer identificat on number FAN) THE CITY OF SOUTH BEND iINDIANA 3 Number and street .'.._._. (or P.twi. t�:a if mail 4s not drs'iveroaf to street address) Iamdrmrtltir 227 WEST JEFFERSON BLVD 4 City, town, or post aiit o . sate, st �r�c6 21P code �-_®.]5 Report number (For IRS Use Only) SOUTH SEND, IN 46601 _El El El 4 fdamu otid Wte of officer or other emp*eo of Issu; or designated u.... onNacl Person vahrarti the, IRS may caf for more rnformatuon 17 Telephone number of, officer or 1ztrepresengaCiau± lirANA Description of Ob16 atlons t:fleCk one: a single issue ❑ or a consolidated return ❑ , 8a Issue price of obligation(s) (see instructions) , . . . . . . _ _ . . . _ . . 8a b Issue date (single issue) or calendar date (consolidated). Enter date in min/dd/yyyy format (for example, 01/01/2009) (see instructions) Ito- 9 Amount of the reported obligation(s) on line 8a that is: a For leases for vehicles . . . . . . . . . . . . . . . . . . . . . . . 9a b For leases for office equipment . . . . . . . . . . . . . . . . . . . . . . 9b c For leases for real property . . . . . . . . . . . . . . . . . . . . . . 9C d For leases for other (see instructions) . . . . . . . . . . . . . . . . . . . . 9d e For bank loans for vehicles . . . . . . . . . . . . . . . . . . . . . . . . 9e f For bank loans for office equipment . . . . . . . . . . . . . . . . . . . . 9f g For bank loans for real property . . . . . . . . . . . . . . . . . . . . . 9 h For bank loans for other (see instructions) . . . . . . . . . . . . . . . . .. 9h i Used to refund prior issue(s) . . . . . . . . . . . . . . . . . . . . . . . 97i i Representing a loan from the proceeds of another tax-exempt obligation (for example, bond bank) . . 9" k Other . . . . . , . . . . . . . . . . . . . . . . . . 9k 10 If the issuer has designated any issue under section 265(b)(3)(13)(1)(111) (small issuer exception), check this box „ 11 If the issuer has elected to pay a penalty in lieu of arbitrage rebate, check this box (see instructions) . . . , 12 Vendor's or bank's name: under penalties of pequry, I declare that I have exmrood This return andaccoorpinying sclted¢d'ss and sWlernnr a, comm, and comnplate. I Pw her declare Ifidt I rvansent to the IRVs dlsclo%te of The issuer's return Wofmral Signature that I have authorized above. and Consent 74— _ Signature of issuer's authorized rep resentative motive Date Paid Prep�arer's signature Date Preparer Print/Type preparer's name .. .... .... ........ Use Only Flrm's address to - General Instructions Section references are to the Internal Revenue Code unfess otherwise noted. What's New The IRS has created a page on IRS.gov for information about the Form 803E series and its instructions, at www.irs.gov/form8038. Information about any future developments affecting the Form 8038 series (such as legislation enacted after we release it) will be posted on that page. Purpose of Form Form 8038-GC is used by the issuers of tax- exempt governmental obligations to provide the IRS with the information required by section 149(e) and to monitor the requirements of sections 141 through 150. Who Must File Issuers of tax-exempt governmental obligations with issue prices of less than $100,000 must rile Form 8038-GC. Issuers of a tax-exempt governmental obligation with an issue price of $100.000 or more must file Form 8038-G, Information Return for Tax -Exempt Governmental Obligations. Filing a separate return for a single issue. Issuers have the option to file a separate Form 8038-GC for any tax-exempt governmental obligation with an issue price of less than $100,000. An issuer of a tax-exempt bond used to finance construction expenditures must file a separate Form 8038-GC for each issue to give notice to the IRS that an election was made to Wd 1e Me h*0 tap my Trrr mImiga and beluer, 11" are as necessary to process the rafune, to the person(s) ........m.. ..........m.m.. Type or print name and title Check ❑ if PTIN self-employed Flrm's EIN ► Phone no. pay a penalty in lieu of arbitrage rebate (see the line 11 instructions). Filing a consolidated return for multiple issues. For all tax-exempt governmental obligations with issue prices of less than $100,000 that are nut reported on a separate Form 8038-GC, an issuer must file a consolidated information return including all such issues issued within the calendar year. Thus, an issuer may file a separate Form 8038-GC for each of a number of small issues and report the remainder of small issues issued during the calendar year on one consolidated Form 8038-GC. However, if the issue is a construction issue, a separate Form 8038-GC must be filed to give the IRS notice of the election to pay a penalty in lieu of arbitrage rebate. Cal. No. 641086 Form 8038-GC (Rev.1-2012)