Form 8038-T Arbitrage Rebate and

(Rev. June 2001) Penalty in Lieu of Arbitrage Rebate OMB No. 1545-1219

 Under Sections 143(g)(3) and 148(f)

and Sections 103(c)(6)(D) and 103A(i)(4) of the Internal Revenue Code of 1954 Department of the Treasury

Internal Revenue Service

Reporting Authority

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

3 Number and street (or P.O. box no. 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

Arbitrage Rebate

Type of issue  Issue price  $

If Form 8038, Form 8038-G, or Form 8038-GC was not filed for this issue, check box 

$

14

Amount of rebate being paid with this form 

15

Period to which payment relates 

$

17

Penalty for failure to pay arbitrage rebate on time (attach statement) 

Elections by the Issuer (see instructions)

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

Did you elect to treat the last day of the bond year on a variable yield issue as the computation date?

Did you elect to treat a transitioned variable yield issue as a fixed yield issue?

24

Did you elect to apply the rules under section 148 to determine if the bond complies with section 103(c)(6)(D) of the

1954 Code?

25

Did you elect to treat a variable yield bond that is not a tender bond as a fixed yield bond after it converted to a fixed rate?

26

Did you elect to continue treating an issue as a variable yield issue after all the bonds in the issue converted to a fixed rate?

27

Did you elect to recompute the yield on a transitioned fixed yield issue?

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 true, correct, and complete.

Sign

Here

Signature of officer Type or print name and title Date

Form 8038-T (Rev. 6-2001)

Part I

Part II



Cat. No. 11545Y

Room/suite

11

Date of the most recently filed (previous) Form 8038-T for this issue: (Month/Day/Year)

12

Is this the final Form 8038-T for this issue? 

Part III Penalty in Lieu of Arbitrage Rebate

18

Check the appropriate box 

 Check box if this Part applies

Part IV

If “Other,” give the number of months since date of issue 

19

Available construction proceeds  $ Unspent  $

If you elected to terminate the election to pay the penalty in lieu of arbitrage rebate,

check one of the following (see instructions):  A B Date election was terminated  

21

Penalty in lieu of rebate  $ or upon termination  $ Total 

22

Penalty for failure to pay on time (attach statement) 

 Check box if this Part applies

To:

Amount of yield reduction payment (see separate instructions) 

13

28

29

30

31

32

33 Did you identify a hedge?

Did you elect to use an actual facts analysis?

Did you elect to exclude earnings on a reasonably required reserve or replacement fund from the definition of available

construction proceeds?

Did you elect to treat the different purposes of a multipurpose issue as separate issues for purposes of the 2-year exception?

Did you elect to treat each loan of a pooled financing issue as a separate issue for purposes of applying the spending exception?

6 months 12 months 18 months 24 months Other

A. Elections made under the 1992 regulations

B. Elections made under the 1993 regulations

Yes  No

Interest on underpayment of arbitrage rebate (see separate instructions)  $

35

Did you apply certain provisions of section 1.148-11A(i) before the effective date?

34



Did you apply certain provisions of section 1.148-11(b) before the effective date?

28

27

29

30

31

32

33

34

35

36

37

39

38

$

$

For Paperwork Reduction Act Notice, see the separate instructions.

Check box if Amended Return 

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

( )

$

$

16

Amount of rebate previously paid with respect to this issue 

20

Interest on underpayment of penalty in lieu of rebate or upon termination (see separate instructions)  $

23

36

37

38

39

/ /

From: (Month/Day/Year) / / (Month/Day/Year) / /

7

Note: For how to pay amounts due, see page 2 of the separate instructions.