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Form 8038-GC Information Return for Small Tax -Exempt Governmental Bond Issues, Leases, and Installment Sales (Rev. January th0-Under Internal Revenue Code section 149(e) OMB No. 1545-0120 Department of thee Treasury T Internal Revenue Service Caution.- If the issue price of the issue fs $100, 000 or more, use Form $038-G. Reporting Aulhority Check box if Amended Return 0- 1 Issuer's name 12 Issuer's employer iderrtifioatian number PIN and street box if mail is 4 City, town, or post office, state, and Z{P oode 6 Report number (For IRS Use Only) SOUTH SEND, IN 46601 1 n n n employee of issuer or person whom the IRS may call for mare Information 17 Telephone number of offiear or Description of Obligations (;neck one: a single issue Cj or a consolidates! return ❑ , Ba Issue price of obligalion(s) (see instructions) . . . . . . . . . . . . . . . . , 8a b Issue date (single issue) or calendar date (consolidated). Enter date in mm/ddlyyyy format (for example, 01/01/2009) (see instructions) Do- 9 Amount of the reported obligation(s) on line $a that Is: a For leases for vehicles . . . . . . . . . . . . . . . . . . , , . gal 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 . . . . . . . . . . . . . . . . ge f For bank loans for office equipment . . . . . . . . . . . . . . . . . . . . 9f g For bank loans for real property. . . . . . . , . . . . . . . 9g h For bank loans for other (see instructions) . . . . . . . . . . . . . . 9h i Used to refund prior issue(s) . . . . . . . . . . . . . . . . . . . . . . . 91 ) Representing a loan from the proceeds of another tax-exempt obligation (for example, bond bank) . . 9i kOther . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9k 10 If the Issuer has designated any Issue under section 265(b)(3)(B)(i)([II) (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 employer identification number: Under perraWes of periury, I declare that I have examined [his return and accompanying schedules and statements, and to the best of my knowledge and belief, they are Signature true, correct, and complete. I fvrlher declare that I consent to the IRS's disclosure of the issuer's return Into mallorr, as necessary to process this return, to the person(s) that I have authorized above, and Consent - Signature of Issuer's authorized representative hate Type or print name and title Paid Printlrype preparer's Warne Preparer's signature 6ata Check Gf i1 PTIIJ Preparer self-employed Use Only Firm's name ■ Firm's Fire r Firm'saddress F Phone no. General instructions Section references are to the Jntemal 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 www.trs.gov1form8038. Information about any future developments affecting the Form 8038 series (such as legislation enacted after we release lt) will be posted on that page. Purpose of Form Form 8038-GO 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 fie 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 finan a Construction expenditures must file a separate Form 8038-GO for each issue to give notice to the IRS that an election was made 10 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 wHh issue prices of less than $100,000 that are not reported on a separate Form 8038430, 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 80$8430. 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.641089 Form 8W8-GC (Rev.'s-2012)