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Form 80'38-Gc Information Return for Small Tax -Exempt (Rev. January 2012) Governmental Bond Issues, Leases, and Installment Sales Department of the Treasury ► Under Internal Revenue Code section 149(e) '' Internal Revenue Service Caution: If the issue price of the issue is $100,000 or more, use Form 8038-G. name THE CITY OF SOUTH BEND I-@1M71AI!J 3 Number and street (or P.O. box if mail is not delivered to street add 4 WEST' JEFFERSON BLVD. tisity, town, or post crfffit;e, state, and ZIP cads SOUTHkl Os.�N...46601.... ..............—......_. .... ..— ----------------- rfi 6 Name and title of officer or other employee of issuer or designated contact person whorn the fP mismom ISt�D 5 Report number (For IRS Use Only) may call for more information i 7 Telephone number of officer or legal representative 574) 245- jM Description of Obligations Check one: a single issue rmm7 or a consolidated return 0. Ba 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) Do- 9 Amount of the reported obligation(s) on line 8a that is: a For leases for vehicles . . . . . . . . . . . . . . . . . . . . . . . . . 9a 9b J .................................. b For leases for office equipment . . . . . . . . . . . . . . . . . . . . . c For leases for real property . . . . 9c 9d d For leases for other (see instructions) . . , .. . . . . , . . . . , . 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) . . . . . . . . . . . . . . . . . . . . . . . 9i 9j j Representing a loan from the proceeds of another tax-exempt obligation (for example, bond bank) k Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9k this box , 10 If the issuer has designated any issue under section 265(b)(3)(13)(i)(111) (small issuer exception), check 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 Vendnr's nr hank's nrrtnlnver Identification nnrnhnr: 958.75 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 Sinature 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(s) g that I have authorized above, and and title Consent Signature of issuer's authorized representative Date___ Type or print name a..... tit Paid Preparer s signature Date Check ❑ it [PTIN Preparer self-employed Pnntf ype preparer's name , ..__.. , � ___ __ �m_—.�..._._ Use Only/ Firm's name ► Firms EIN i Firm's address ► Phone no. General Instructions Section references are to the Internal Revenue Code unless otherwise noted. 1 i'lfFSW ►C.I The IRS has created a page on IRS.gov for information about the Form 8038 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 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 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 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, 641088 Form 8038-GC (Rev. 1-2012)