Form 8038-GC Issuer's name (Rev. January 2012) Department of the Treasury Internal Revenue Service Information Return for Small Tax-Exempt Governmental Bond Issues, Leases, and Installment Sales Under Internal Revenue Code section 149(e) Caution: If the issue price of the issue is $100,000 or more, use Form 8038-G. OMB No. 1545-0720 Part I 1 Reporting Authority Check box if Amended Return 2 Issuer's employer identification number (EIN) 3 Number and street (or P.O. box if mail is not delivered to street address) Room/suite 4 6 City, town, or post office, state, and ZIP code 5 Report number (For IRS Use Only) Name and title of officer or other employee of issuer or designated contact person whom the IRS may call for more information 7 Telephone number of officer or legal representative Part II Description of Obligations Check one: a single issue or a consolidated return . 8a Issue price of obligation(s) (see instructions) . . . . . . . . . . . . . . . . . . 8a b Issue date (single issue) or calendar date (consolidated). Enter date in mm/dd/yyyy format (for example, 01/01/2009) (see instructions) 9 Amount of the reported obligation(s) on line 8a that is: a For leases for vehicles ......................... 9a b For leases for office equipment . . . . . . . . . . . . . . . . . . . . . . . 9b c For leases for real property . . . . . . . . . . . . . . . . . . . . . . . . 9c d For leases for other (see instructions) . . . . . . . . . . . . . . . . . . . . . 9d e For bank loans for vehicles . . . . . . . . . . . . . . . . . . . . . . . . 9e f For bank loans for office equipment . . . . . . . . . . . . . . . . . . . . . 9f g For bank loans for real property. . . . . . . . . . . . . . . . . . . . . . . 9g h For bank loans for other (see instructions) . . . . . . . . . . . . . . . . . . . 9h i Used to refund prior issue(s) ....................... 9i j Representing a loan from the proceeds of another tax-exempt obligation (for example, bond bank) . . 9j k Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9k 10 If the issuer has designated any issue under section 265(b)(3)(B)(i)(III) (small issuer exception), check this box . 11 If the issuer has elected to pay a penalty in lieu of arbitrage rebate, check this box (see instructions) . . . . 12 Vendor's or bank's name: 13 Vendor's or bank's employer identification number: . . . . . . Signature and Consent Paid Preparer Use Only 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(s) that I have authorized above. Signature of issuer's authorized representative Print/Type preparer's name Preparer's signature Date Date Type or print name and title Check if self-employed Firm's EIN Phone no. PTIN Firm's name Firm's address General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Who Must File Issuers of tax-exempt governmental obligations with issue prices of less than $100,000 must file Form 8038-GC. Issuers of a tax-exempt governmental obligation with an issue price of $100,000 or more must file Form 8038-G, Information Return for Tax-Exempt Governmental Obligations. Filing a separate return for a single issue. Issuers have the option to file a separate Form 8038-GC for any tax-exempt governmental obligation with an issue price of less than $100,000. An issuer of a tax-exempt bond used to finance construction expenditures must file a separate Form 8038-GC for each issue to give notice to the IRS that an election was made to pay a penalty in lieu of arbitrage rebate (see the line 11 instructions). Filing a consolidated return for multiple issues. For all tax-exempt governmental obligations with issue prices of less than $100,000 that are not reported on a separate Form 8038-GC, an issuer must file a consolidated information return including all such issues issued within the calendar year. Thus, an issuer may file a separate Form 8038-GC for each of a number of small issues and report the remainder of small issues issued during the calendar year on one consolidated Form 8038-GC. However, if the issue is a construction issue, a separate Form 8038-GC must be filed to give the IRS notice of the election to pay a penalty in lieu of arbitrage rebate. What's New The IRS has created a page on IRS.gov for information about the Form 8038 series and its instructions, at www.irs.gov/form8038. Information about any future developments affecting the Form 8038 series (such as legislation enacted after we release it) will be posted on that page. Purpose of Form Form 8038-GC is used by the issuers of taxexempt governmental obligations to provide the IRS with the information required by section 149(e) and to monitor the requirements of sections 141 through 150. Cat. No. 64108B Form 8038-GC (Rev. 1-2012) American LegalNet, Inc. www.FormsWorkFlow.com Form 8038-GC (Rev. 1-2012) Page 2 When To File To file a separate return for a single issue, file Form 8038-GC on or before the 15th day of the second calendar month after the close of the calendar quarter in which the issue is issued. To file a consolidated return for multiple issues, file Form 8038-GC on or before February 15th of the calendar year following the year in which the issue is issued. Late filing. An issuer may be granted an extension of time to file Form 8038-GC under section 3 of Rev. Proc. 2002-48, 2002-37 I.R.B. 531, if it is determined that the failure to file on time is not due to willful neglect. Type or print at the top of the form, "Request for Relief under section 3 of Rev. Proc. 2002-48." Attach to the Form 8038-GC a letter briefly stating why the form was not submitted to the IRS on time. Also indicate whether the obligation in question is under examination by the IRS. Do not submit copies of any bond documents, leases, or installment sale documents. See Where To File next. multiple tax-exempt governmental obligations if the form is used for consolidated reporting. Tax-exempt obligation. This is any obligation including a bond, installment purchase agreement, or financial lease, on which the interest is excluded from income under section 103. Tax-exempt governmental obligation. A tax-exempt obligation that is not a private activity bond (see below) is a