rom 8038-GC

(Rev. October 1989)

Department of the Treasury
Internal Revenue Service

> For calendar year ending 19

Consolidated Information Return for Small Tax-Exempt
Governmental Bond Issues, Leases and Installment Sales

> Under Section 149(e)
(Use Form 8038-G if the issue price of the issue is $100,000 or more.)

OMB No. 1545-0720
Expires 05/31/92

Reporting Authority

Check box if Amended Return > [_]

1 Issuer's name

2 Issuer's employer identification number

3 Number and street

4 City or town, state, and ZIP code

| Part 11 | Description of Obligations

5 Total issue price of all small tax-exempt governmental obligations issued during the calendar year .

6 Check the box that most nearly approximates the weighted average maturity of the obligations:

aC Less than 5 years
b C) From5 to 10 years
cL More than 10 years

7 Check the box that most nearly approximates the weighted average interest rate on the obligations:

aC Less than 5%
b C) From 5% to 10%
¢ C1] More than 10%

8 Total issue price of the obligations reported on line 5 that are:

a Obligations issued in the form of a lease or installment sale .

b Obligations designated by the issuer under section 265(b)(3)(B)(i)(III)

¢ Obligations issued to refund prior issues

d Loans made from the proceeds of another tax-exempt obligation

.

8a

8b

t
8c

8d_|

| Under penalties of perjury, | 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.

Please
Sign
Here

| » Signature of officer

Date

Vix or print name and title

General Instructions

(Section references are to the Internal
Revenue Code unless otherwise noted.)

Paperwork Reduction Act Notice

We ask for this information to carry out the
Internal Revenue laws of the United States.
We need it to ensure that you are complying
with these laws. You are required to give us
this information.

The time needed to complete and file this
form varies depending on individual
circumstances. The estimated average time
is:

Recordkeeping . 3hrs., 21 min.
Learning about the

Jaw or the form Lhr., 34 min.
Preparing the form. 2hrs., 37 min.
Copying, assembling, and
sending the formtoIRS . .16 min.

If you have comments concerning the
accuracy of this time estimate or
suggestions for making this form more
simple, we would be happy to hear from
you. You can write to either the Internal
Revenue Service, Washington, DC 20224,
Attention: IRS Reports Clearance Officer,
T:FP; or the Office of Management and
Budget, Paperwork Reduction Project
(1545-0720), Washington, DC 20503.

Item You Should Note

Agovernmental unit is required to file this
form for all small tax-exempt governmental
obligations on which it pays interest. These
obligations include bonds, leases and
installment sales.

Purpose of Form

Form 8038-GC is to be used by issuers of
tax-exempt governmental obligations to
provide IRS with the information required by
section 149(e) and to monitor the
requirements of sections 141 through 150.

Who Must File

Each issuer must file Form 8038-GC for all
tax-exempt governmental bonds, leases and
installment sales issued during the calender
year, with an issue price of less than
$100,000. Form 8038-G is filed to report
each issue of governmental obligations with
issue prices of $100,000 or more.

When To File

File Form 8038-GC on or before February
15th after the close of the calendar year in
which the issue Is issued. Form 8038-GC
must be completed based on the facts as of
the close of the calendar year.

Late filing. —A Form 8038-GC filed after
the due date may be granted an extension
of time to file under section 3 of Rev. Proc.
88-10, 1988-1 C.B. 635, if it s determined
that the failure to file in a timely manner is
not due to willful neglect. A late Form

Form 8038-GC (Rev. 10-89)


Form 8038~GC (Rev. 10-89)

Page 2

8038-GC should be sent to: Internal
Revenue Service, Philadelphia Service
Center, Statistics of Income Unit, P:DA:
Unit F-SOI, Philadelphia, PA 19255, Stop
#335. Type or print at the top of the form,
“This Statement Is Submitted in
Accordance with Rev. Proc. 88-10.” Attach
to the Form 8038-GC a letter briefly setting
forth the reasons why Form 8038-GC was
not submitted to the IRS on time, and also
indicating whether the obligation in
question is under examination by the IRS.
Do not submit copies of any bond
documents, leases or installment sale
documents.

Where To File

File Form 8038-GC with the Internal
Revenue Service Center, Philadelphia, PA
19255,

Definitions

© A tax-exempt obligation is not limited to
the formal issuance of bonds. It also
includes installment purchase agreements
and financial leases.

@ A tax-exempt governmental obligation
is a tax-exempt obligation that is not a
private activity bond.

© A private activity bond is generally an
obligation issued as part of an issue of
which: (1) More than 10% of the proceeds
are to be used for any private business use;
and (2) More than 10% of the payment of
principal or interest of the issue is either
secured by an interest in property to be
used for a private business use (or
payments in respect of such property), or is
to be derived from payments in respect of
property (or borrowed money) used for a
private business use. An obligation is also
considered a private activity bond if the
amount of the proceeds to be used to make
or finance loans (other than loans described
in section 141(c)(2)) to certain persons
exceeds the lesser of 5% of the proceeds, or
$5,000,000. Private activity bonds should
be reported on Form 8038, Information
Return for Tax-Exempt Private Activity Bond
Issues.

© Issue —Generally, separate obligations

should not be treated as part of the same
issue if the obligations are not issued by the

same issuer, on the same date, and
pursuant to a single transaction (or series of
related transactions). With respect to
draw-down loans, all amounts reasonably
expected to be advanced within 3 years of
the date of the first draw may be treated as
part of the same issue if the draws are
equally and ratably secured by the same
loan agreement and are pursuant toa
common financing arrangement. All
obligations that are issued pursuant toa
single finance lease or installment
purchase agreement may be treated as.
part of the same issue if all of the property
covered by that agreement is reasonably
expected to be delivered within 3 years of
the date of issue of the first obligation.

Specific Instructions
Part |.—Reporting Authority

Amended Return.—If you are filing an
amended Form 8038-GC, check the
amended return box and complete Part |
and only those parts of Form 8038-GC you
are amending by entering the correct
information. Do not file an amended Form
8038-GC to amend estimated amounts you
previously reported once the actual
amounts are determined. (See the Part II
instruction, below.)

Line 1.—The issuer's name is the name of
the entity issuing the obligations, not the
name of the entity receiving the benefit of
the financing. In the case of a lease or
installment sale, the issuer is the lessee or
purchaser.

Line 2—Issuer's employer identification
number (EIN).—If the issuer does not have
an employer identification number, enter
“none” and attach a completed Form SS-4,
Application for Employer Identification
Number, to Form 8038-GC. If, however, the
issuer has previously applied for such a
number, attach a statement giving the date
of the application and the office where it
was submitted.

Part Il.—Description of Obligations

This part may be completed based on
information readily available to the issuer
at the close of the calendar year,

supplemented by estimates made in good
faith. All entries may be based on good
faith approximations.

Line 5.—Enter the total issue price of all
small tax-exempt governmental obligations
issued during the calendar year. Small
governmental obligations means those with
an issue price of less than $100,000. If the
obligations are reoffered to the public by an
intermediary, the issue price is the
reoffering price (excluding accrued
interest).

The issue price of an obligation means
the principal amount due on the obligation
and does not include interest paid or to be
paid. Therefore line 5 should include only
the principal amount due on obligations
sold during the calendar year. For example,
only the purchase price of an asset acquired
pursuant to a Jease should be included on
Line 5 and only in the year such lease is
entered into. A lease or installment sale is
treated as issued on the date interest starts
to accrue.

Line 6.—The weighted average maturity is
the average maturity on the obligations.
With respect to bonds, each bond should be
weighted to its par value. For a lease or
installment sale, enter the total number of
years the lease or installment sale will be
outstanding.

Line 7.— The weighted average interest
rate is the average interest rate on the
obligations. Each bond should be weighted
in proportion to its par value and its length
of maturity.

Line 8.—Enter the total issue price of the
obligations reported on line 5 that are
described on lines 8a, 8b, 8c, and 8d. More
than one line may apply to a particular
obligation. For example, obligations issued
to refund prior issues which were
designated by the issuer under section
265(b)(3)(B)(i)(III) should be reported on
line 8b and line 8c.

Signature

Form 8038-GC must be signed by an
authorized representative of the issuer. Also
print the name and title of the person
signing the Form 8038-GC.