Request for Recovery of Overpayments

Under Arbitrage Rebate Provisions

Form 8038-R

OMB No. 1545-1750

Department of the Treasury

Internal Revenue Service  See instructions on back.

Reporting Authority

1 Issuer’s name 2 Issuer’s employer identification number

3 Number and street (or P.O. box if mail is not delivered to street address) 4 Report number

5 City, town, or post office, state, and ZIP code 6 Date of issue

7 Name of issue 8 CUSIP number

Request for Refund of Amounts Paid Under Rebate Provisions (see instructions)

12 Total amount paid under rebate provisions

19

20

16

18

21

19

20

Other Information (see instructions)

For Paperwork Reduction Act Notice, see back of form. Form 8038-R (11-2001)

Part III

Part I

Part II

Cat. No. 57334H

(November 2001)

Room/suite

9 Name and title of officer or legal representative whom the IRS may call for more information 10 Telephone number of officer or legal representative

( )

21

Rebate amount as of the most recent computation date

Amounts (not included in line 12) required to be paid under section

148 as of the date the recovery is requested

Add lines 13 and 14

Amount of overpayment. Subtract line 15 from line 12

Schedule of payments (see instructions). Attach additional sheets if necessary.

Was the overpayment paid as penalty in lieu of rebate under section 148(f)(4)(C)(vii)? 

Has the final computation date for the issue occurred? 

Is the issue comprised of qualified redevelopment, qualified small issue, or exempt facilities bonds? If “Yes,”

provide name and EIN of the primary private user.

Check the “Yes” or “No” box for each question below. Yes No

Under penalties of perjury, I declare that I have examined this request for recovery of overpayment, including accompanying schedules and

statements, and to the best of my knowledge and belief, the facts represented in support of the request are true, correct, and complete.

Sign

Here  Signature of issuer’s authorized representative Date Type or print name and title 

13

14

15

 File a separate form for each issue.

11 If the issue is outstanding on June 30, 1993, and the issuer elects not to apply the 1992 regulations, check here (see

instructions) 

17 Computations and relevant facts that led to overpayment (see instructions). Attach additional sheets if necessary.

12

15

16

13

14

Name  EIN 
General Instructions

Section references are to the Internal Revenue Code unless

otherwise noted.

Note: Use a separate Form 8038-R for each issue.

Purpose of Form

Form 8038-R is used by issuers of state and local bonds to

request a refund of amounts paid with Form 8038-T, Arbitrage

Rebate and Penalty in Lieu of Arbitrage Rebate.

Note: Form 8038-R replaces the letter procedure of Rev. Proc.

92-83, 1992-2 C.B. 487.

Payments made with Form 8038-T that may be recoverable

include:

1. Yield reduction payments,

2. The arbitrage rebate to the United States,

3. A penalty in lieu of rebating arbitrage to the United States,

or

4. A penalty to terminate the election to pay a penalty in lieu

of rebating arbitrage.

Recovery of Overpayment

In general, an issuer may recover an overpayment of rebate for

an issue of tax-exempt bonds by establishing to the Internal

Revenue Service that the overpayment occurred. An

overpayment is the excess of the amount paid to the United

States for an issue under section 148 over the sum of the rebate

amount for the issue as of the most recent computation date

and all amounts that are otherwise required to be paid under

section 148 as of the date the recovery is requested.

An overpayment may be recovered only to the extent that a

recovery on the date that it is first requested would not result in

an additional rebate amount if that date were treated as a

computation date.

Except for overpayments of penalty in lieu of rebate under

section 148(f)(4)(C)(vii) and Regulations section 1.148-7(k), an

overpayment of less than $5,000 may not be recovered before

the final computation date. See Regulations section 1.148-3(i).

Processing the Request

Generally, the information requested on Form 8038-R will be

sufficient to determine whether a refund is appropriate. However,

if additional information is necessary, the IRS will contact the

issuer or its representative. Processing of the request will then

be suspended and the issuer will have 30 calendar days to

submit the requested information. If all the requested information

is not timely received, a letter will be sent explaining that the

request for recovery is deficient and that its processing is

terminated. This letter may also be sent instead of a request for

additional information if the initial request for recovery is severely

deficient.

Any proposed adverse determination may be appealed. See

Rev. Proc. 99-35, 1999-2 C.B. 501, for details.

Where To File

File Form 8038-R, and any attachments, with the Internal

Revenue Service Center, Ogden, UT 84201.

Signature

Form 8038-R must be signed by an authorized representative of

the issuer. Also type or print the name and title of the person

signing Form 8038-R.

Specific Instructions

Part I—Reporting Authority

Line 1. Enter the name of the governmental entity that issued

the bonds, not the name of the entity receiving the benefit of the

financing.

Line 6. Enter the date of issue. This is generally the first date on

which there is a physical exchange of the bonds for the

purchase price.

Line 7. Enter the name of the issue. If there is no name, please

provide other identification of the issue.

Line 8. Enter the CUSIP (Committee on Uniform Securities

Identification Procedures) number of the bond with the latest

maturity. Enter “None” if the issue does not have a CUSIP

number.

Part II—Request for Refund

Line 17. Provide the computations of the overpayment paid as

part of a rebate payment, penalty in lieu of rebate, or to

terminate the penalty in lieu of rebate. Also, include the

computations for interest (if any). If relevant, a description of the

facts that led to the overpayment may also be included.

Line 18. Provide a schedule showing amounts and dates that

payments were made to the United States for the issue. Do not

attach copies of Form(s) 8038-T that accompanied payments to

the United States; doing so may delay your request.

Part III—Other Information

Line 20. The final computation date is the date the issue is

discharged. For details, see Regulations section 1.148-3(e)(2).

Line 21. Check the “Yes” box if:

The issue is comprised of... As described in section...

Qualified redevelopment bonds 144(c)

Qualified small issue bonds 144(a)

Exempt facilities bonds 142(a)(4) through 142(a)(11)

and 142(a)(13)

If one of the above applies, then enter the name and employer

identification number (EIN) of the primary private user. A “private

user” is the nongovernmental entity that meets the private

business tests of section 141(b) or private loan financing test of

section 141(c).

Paperwork Reduction Act Notice. We ask for the information

on this form to carry out the Internal Revenue laws of the United

States. You are required to give us the information. We need it

to ensure that you are complying with these laws.

You are not required to provide the information requested on a

form that is subject to the Paperwork Reduction Act unless the

form displays a valid OMB control number. Books or records

relating to a form or its instructions must be retained as long as

their contents may become material in the administration of any

Internal Revenue law. Generally, tax returns and return

information are confidential, as required by section 6103.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated average

time is: Recordkeeping, 5 hr., 44 min.; Learning about the law

or the form, 3 hr., 10 min.; Preparing, copying, assembling,

and sending the form to the IRS, 3 hr., 24 min.

If you have comments concerning the accuracy of these time

estimates or suggestions for making this form simpler, we would

be happy to hear from you. You can write to the Tax Forms

Committee, Western Area Distribution Center, Rancho Cordova,

CA 95743-0001. Do not send the form to this address. Instead,

see Where To File above.

Form 8038-R (11-2001) Page 2

Line 11. Current Regulations sections 1.148-1 through 1.148-11

apply to issues outstanding after June 30, 1993. If the issue was

outstanding prior to July 1, 1993, the 1992 regulations apply

(i.e., Regulations sections 1.148-1 through 1.148-12 effective

May 18, 1992 (T.D. 8418, 1992-1 C.B. 29)). However, check the

box if the issue was outstanding prior to July 1, 1993, and the

issuer has elected not to apply the 1992 regulations; the current

Regulations sections 1.148-1 through 1.148-11 apply.