For Office Use Only STATE OF CALIFORNIA MARKS-ROOS YEARLY FISCAL STATUS REPORT FOR LOAN OBLIGATIONS Fiscal Year ________________ CDIAC # ______________ California Debt and Investment Advisory Commission 915 Capitol Mall, Room 400, Sacramento, CA 95814 P.O. Box 942809, Sacramento, CA 94209-0001 Tel: (916) 653-3269 FAX (916) 654-7440 California Government Code Section 6599.1 requires that all issuers selling Mark-Roos bonds, which is part of the Mark-Roos Local Bond Pooling Act of 1985, after January 1, 1996 are required to report specific information to the Commission by October 30th of the current year and each year thereafter, until maturity. I. GENERAL INFORMATION A. Local Obligation Loan Recipient _________________________________________________________ B. Date of Loan _________________________________________________________ C. Original Principal Amount of Loan $ _________________________________________________________ D. Name of Authority Issuing Loan _________________________________________________________ E. Title of Authority Bond Issue _________________________________________________________ _________________________________________________________ F. Date of Authority Bond Issue __________________________ CDIAC # ________________________________________ G. Reserve Fund Minimum Balance Required Yes No Amount $ ______________________________ Part of Authority Reserve Fund II. Yes Percent of Reserve Fund _________________ LOAN and FUND BALANCE FISCAL STATUS Balances Reported as of: A. Principal Amount of Loan Outstanding June 30, ____________ (Year) $ ___________________________ B. Bond Reserve Fund $ ___________________________ C. Capitalized Interest Fund $ ___________________________ III. DELINQUENT REPORTING INFORMATION (Complete if Taxes are the Source of Repayment) Are Taxes the Source of Repayment for the Loan? Yes No If “Yes” - Type of Tax: __________________________________________________ Delinquency Reported on Tax Collection on (Date): ____________________________ A. Delinquency Rate B. Are the Property Taxes Paid Under the County’s Teeter Plan IV. (Percent) Yes No RETIRED ISSUES This loan has been repaid and is no longer subject to the Yearly Fiscal Status report filing requirements. (Indicate how repaid) ________________________________________________________________ ________________________________________ V. NAME OF PARTY COMPLETING THIS FORM Name ___________________________________________________________________________________________________ Title ___________________________________________________________________________________________________ Firm/Agency _____________________________________________________________________________________________ Address ________________________________________________________________________________________________ City/State/Zip ____________________________________________________________________________________________ Phone ______________________________________________ Date of Report ______________________________________ Email: _______________________________________________ G:\FORMS\Current Debt Issuance Forms\MKR LOAN.doc 10/5/2011 American LegalNet, Inc. www.FormsWorkFlow.com