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Fan, 8038-0 (Rev. January 2012) Department of the Treasury Internal Revenue Service 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 Foma 8038-G. ONIS No, 1545-0720 1 Issuer's name 2 Issuer's employer Identification number (EIN) THE CITY OF SOUTH BEND, INDIANA 3 Number and street (or R0, box it mail Is not delivered to street address) Hoorwsuite 227 WEST JEFFERSON BLVD 4 City, town, or post office, state, and 2tP code 5 Report number (For IRS Use Only) SOUTH BENDr IN 46601 07 I B Name and title of officer w other employee of issue(or designated conlact person whom the IRS may call for more InfomratIon 7 Tolephone number of officer at legal representatrva 574 245.6205 Lleacnptlon of Mligalions unecK one: a single Issue IJ or a consonclatea return ❑ . Sa Issue price of obltgation(s) (see Instructions) . . . . . . . . . . . . . . . . . . 8a b Issue date (single Issue) or calendar date (consolidated). Enter date In mm/dd/yyyy format (fora, r example, 01/01/2009) (see instructions) 0- 9 Amount of the reported obligation(s) on fine Ba that is; a For leases for vehicles . . . . . . . . . . . . . . . . . . . . . . . . . 9a b For leases for office equipment . . . . . . . . . . . . . . . . . . . . . . . 9b c For leases for real property . . . . . . . . . . . , . . . 90 d For leases for other (see instructions) . . . . . . . . . . . . . . . . . 9d e For bank loans for vehicles . . . . . . . . . . . . . . . . . . . . . . . . 9e f For -bank loans for office equipment . . . . . . . . . . . . . . . . . . . . . of 9 For bank loans for real property. . . . . . . . 9 h For bank loans for other (see instructions) . . . , , . . . . . . . . . . . . . 9h 1 Used to refund prior Issues) . . . . . . . . . . . . . . . . . . . . . . . 9i I Representing a loan from the proceeds of another tax-exempt obligation (for example, bond bank) 91 kOther . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9k 10 If the issuer has designated any issue under section 265(b)(3)(B)(i)(I11) (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 banks name; 13 'Vpndnr'�, nr hank'Q P.m nrnunr lelpntjfir•afinn nr,mkm-, Signature and Consent Paid Preparer Use Only hder perraltles of penury, I declare that I have examined this retum and awAxnpanyfing schedules and statements, and to the best of my knowledge and berief, they are ue, correct, and complete. I further declare that f consent to the IRS's discbsure of the issuer's return information, as necessary to process this return, (o the person(s) at I have auguired above, -7 4- Signature of issuer's authorized representative Date Type or print name and Attie ;UTYpe praparer's name Preparers signature Date check 0 if "" Pinn's name i► Firm's EIN ■ Firm's address I► Phone no. General Instructions Section references are to the Internal Revenue Code unless otherwise noted. What's New The IRS has created a page on IR8,gov for Information about the Fotm 803B series and Its instructions, at wwwJrs.gov/fonnW38. Information about any future developments affect#ng the Form 8038 series (such as legislation enacted after we release €t) will be posted on that page. Purpose of Form Form 8039-G0 is used by the Issuers of tax- exempt governmental obligations to provide the IRS with the information required by section 14g(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 808-G0. Issuers of a tax-exempt govemmental obligation with an issue price of $100,000 or more must file Form 8038-G, Information Return forTex-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 band 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 lax -exempt governmental obligations with issue prices of less than $100,000 that are not reported on a separate Form 8038-CC, an issuer must V@ a consolidated information return inotuding all such issues issued within the calendar year. Thus, an issuer may fife 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-GG, 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.64103B Form SOM-112110 (Rev, 1-2012)