Information Return for Tax-Exempt

Private Activity Bond Issues Form 8038 OMB No. 1545-0720

(Under Internal Revenue Code section 149(e)) Department of the Treasury

Internal Revenue Service © See separate instructions.

Reporting Authority Check if Amended Return ©

1 Issuer’s name 2 Issuer’s employer identification number (EIN)

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

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

7 Name of issue 8 CUSIP number

Type of Issue (Enter the issue price for each) Issue Price

11 Exempt facility bond:

11a a Airport (sections 142(a)(1) and 142(c))

b Docks and wharves (sections 142(a)(2) and 142(c)) 11b

11d d

Water furnishing facilities (sections 142(a)(4) and 142(e))

11e e

Sewage facilities (section 142(a)(5))

11f f

Solid waste disposal facilities (section 142(a)(6))

Qualified residential rental projects (sections 142(a)(7) and 142(d)) (see instructions)

Meeting 20–50 test (section 142(d)(1)(A))

Meeting 40–60 test (section 142(d)(1)(B))

Meeting 25–60 test (NYC only) (section 142(d)(6))

Has an election been made for deep rent skewing (section 142(d)(4)(B))? Yes No

Facilities for the local furnishing of electric energy or gas (sections 142(a)(8) and 142(f)) 11g

h

i

Facilities allowed under a transitional rule of the Tax Reform Act of 1986 (see instructions) 11h

Facility type

1986 Act section

11j

Qualified mortgage bond (section 143(a))

Qualified veterans’ mortgage bond (section 143(b)) (see instructions) © 13

Check the box if you elect to rebate arbitrage profits to the United States

Qualified small issue bond (section 144(a)) (see instructions) © 14

12a

Check the box for $10 million small issue exemption

16

Qualified student loan bond (section 144(b))

13

17

Qualified redevelopment bond (section 144(c))

14

18

Qualified hospital bond (section 145(c)) (attach schedule—see instructions) 

15

Qualified 501(c)(3) nonhospital bond (section 145(b)) (attach schedule—see instructions) 

16

19

Check box if 95% or more of net proceeds will be used only for capital expenditures ©

17

18

Description of Bonds (Complete for the entire issue for which this form is being filed.)

(c) Stated redemption

price at maturity

(d) Weighted

average maturity

(a) Final maturity date (b) Issue price (e) Yield

21 $ $ years %

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form 8038 (Rev. 6-2010)

Part III

Part I

Part II

Cat. No. 49973K

(Rev. June 2010)

Room/suite

Qualified enterprise zone facility bonds (section 1394) (see instructions) 11i

9 Name and title of officer of the issuer or other person whom the IRS may call for more information 10 Telephone number of officer or other person

( )

c 11c

g

20a

19 Nongovernmental output property bond (treated as private activity bond) (section 141(d))

j Qualified empowerment zone facility bonds (section 1394(f)) (see instructions) 

m Qualified green building and sustainable design projects (sections 142(a)(14) and 142(l)) 11m

12a

15

k District of Columbia Enterprise Zone facility bonds (section 1400A) 11k

l Qualified public educational facility bonds (sections 142(a)(13) and 142(k)) 11l

n Qualified highway or surface freight transfer facilities (sections 142(a)(15) and 142(m)) 11n

o

p

q

Qualified New York Liberty bonds (section 1400L(d)) © 11p

11q

b

20b

Other. Describe (see instructions) © 20c

b

c

Other (see instructions)

New York Liberty Zone advance refunding bond (section 1400L(e)) (see instructions)

Other (see instructions)

Other (see instructions)

Other (see instructions)

Report number (For IRS Use Only)

1

12b
Form 8038 (Rev. 6-2010) Page 2

Uses of Proceeds of Issue (including underwriters’ discount) Amount

22 Proceeds used for accrued interest 22

23 Issue price of entire issue (enter amount from line 21, column (b)) 23

24 Proceeds used for bond issuance costs (including underwriters’ discount) 24

25 Proceeds used for credit enhancement 25

26 Proceeds allocated to reasonably required reserve or replacement fund 26

27 27

29 Add lines 24 through 28 29

30 Nonrefunding proceeds of the issue (subtract line 29 from line 23 and enter amount here) 30

Description of Property Financed by Nonrefunding Proceeds

31 Type of Property Financed by Nonrefunding Proceeds:

a Land 31a

b Buildings and structures 31b

c Equipment with recovery period of more than 5 years 31c

d Equipment with recovery period of 5 years or less 31d

e 31e

32 North American Industry Classification System (NAICS) of the projects financed by nonrefunding proceeds.

NAICS Code Amount of nonrefunding proceeds NAICS Code Amount of nonrefunding proceeds

a c

b d

Description of Refunded Bonds (Complete this part only for refunding bonds.)

33 Enter the remaining weighted average maturity of the bonds to be currently refunded © years

35 Enter the last date on which the refunded bonds will be called ©

36 Enter the date(s) the refunded bonds were issued ©

Miscellaneous

37 Name of governmental unit(s) approving issue (see the instructions) ©

38 Check the box if you have designated any issue under section 265(b)(3)(B)(i)(III) ©

Volume Caps

42 Amount of state volume cap allocated to the issuer. Attach copy of state certification 42

43 Amount of issue subject to the unified state volume cap 43

44 Amount of issue not subject to the unified state volume cap or other volume limitations:

a Of bonds for governmentally owned solid waste facilities, airports, docks, wharves, environmental

enhancements of hydroelectric generating facilities, or high-speed intercity rail facilities 

44

44a

b Under a carryforward election. Attach a copy of Form 8328 to this return 44b

c Under transitional rules of the Tax Reform Act of 1986. Enter Act section © 44c

d Under the exception for current refunding (section 146(i) and section 1313(a) of the Tax Reform Act of 1986) 44d

45a

45b

46a

45a Amount of issue of qualified veterans’ mortgage bonds

b Enter the state limit on qualified veterans’ mortgage bonds 

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. I further declare that I consent to the IRS’s disclosure of the issuer’s return information, as necessary

to process this return, to the person that I have authorized above. Signature

and

Consent

Signature of issuer’s authorized representative Date

Part VIII

Part VII

Part VI

Part V

Part IV

Amount

Amount

© ©

39 Check the box if you have elected to pay a penalty in lieu of arbitrage rebate ©

$

$ $

$

40 Check the box if you have identified a hedge (see instructions) ©

Caution: The total of lines 31a through e below must equal line 30 above. Do not complete for qualified student loan

bonds, qualified mortgage bonds, or qualified veterans’ mortgage bonds.

46a Amount of section 1394(f) volume cap allocated to issuer. Attach copy of local government certification 

b Name of empowerment zone ©

28

Proceeds used to currently refund prior issue (complete Part VI) 

28 Proceeds used to advance refund prior issue (complete Part VI) 

34 Enter the remaining weighted average maturity of the bonds to be advance refunded © years

47 Amount of section 142(k)(5) volume cap allocated to issuer. Attach copy of state certification 47

Check the box if the issue is comprised of qualified redevelopment, qualified small issue, or exempt facilities bonds and

provide name and EIN of the primary private user ©

41

Name © EIN

Date Preparer’s SSN or PTIN Preparer’s

signature Check if

self-employed

Paid

Preparer’s 

Use Only Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

Phone no.

©

© ( )

Type or print name and title

Other. Describe (see instructions) ©