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Form 03 -GC (Rev. January 2012) Department of the Treasury Internal Revenue Service name street Information Return for Small Tax -Exempt Governmental Bond Issues, Leases, and Installment Sales ► Under Internal Revenue Code section 149(e) Caution: If the issue Price of the issue is $100,000 or more, use Form 8038-G. delivered to street address) 227 WEST JEFFERSON BLVD. 4 City, town, or post office, state, and ZIP code or ollter employee of issuer or designated contact person whom the IIRS may caul for more OMB No. 1545-0720 employer identification number Room/suite 5 Report number (For IRS Use Only) number of officer or legal representative jM Description of Obligations Ohee'1< one: a single Issue [,j or a consoimateea return ". 8a Issue price of obligation(s) (see instructions) . . . . . . . . . . . . . . 8a b Issue date (single issue) or calendar date (consolidated). Enter date in mm/dd/yyyy format (for example, 01/01/2009) (see instructions) No- 9 Amount of the reported obligation(s) on line 8athat 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) . . . . . . . . . . . . . . . . . . . . . I l j 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)(i)(III) (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: 13 Vendor's or bank's empfov r od(anttlftcation number: n p as no Me y WWI, and belief, they are Under penalties of perjury, I declare that I have examined this rettarn and acrc;ompartiytlrtyg S,cPredclas and statements, ttnaf tl'o throe Etrtsf of m knowledge Signature true, correct, and complete. I further declare that I consent to the &RS s disclosum 0 the issuer's s iettarn information, necessary to process thisI, to the person(s) 7 that I have authorized above. and Consent .-._ Signature of issuer's authorized representative Date . ...................................... Paid Print/Type preparer's name Preparer's signature Preparer oat mm Use Only Firm's name ► Firm's address No - General Instructions Section references are to the Intemal Revenue Code unless otherwise noted. What's New The IRS has created a page on IRS.gov for information about the Form 8038 series and its instructions, at wwwJrs.gov1form8038. 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 monitorthe requirements of sections 141 through 150. Who Must File Issuers of tax-exempt governmental obligations with issue prices of less than $100,000 must file 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 Retum 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 Type or print name and title e Check ❑ if PTIN self-employed Firm'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 not 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. Cat. No. 64108B Form 8038-GC (Rev. 1-2012)