Information Return for Small Tax-Exempt   
Form 8038-GC                    Governmental Bond Issues, Leases, and Installment Sales 
(Rev. October 2021)                                   ▶ Under Internal Revenue Code section 149(e)                                                     OMB No. 1545-0047 
Department of the Treasury         Caution: If the issue price of the issue is $100,000 or more, use Form 8038-G. 
Internal Revenue Service          ▶ Go to www.irs.gov/Form8038GC for instructions and the latest information.
Part I   Reporting Authority                                                                                  Check box if Amended Return ▶
1   Issuer’s name                                                                                                                 2   Issuer’s employer identification number (EIN)

3   Number and street (or P.O. box if mail isn’t delivered to street address)                                                                          Room/suite 

4   City, town, or post office, state, and ZIP code                                                                               5   Report number (For IRS Use Only) 

6   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 box:                Single issue        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:
                  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 
Signature         process this return, to the person(s) that I have authorized above. 
and               ▲                                                                                         ▲

Consent 
                    Signature of issuer’s authorized representative                     Date                                      Type or print name and title 
         Print/Type preparer’s name                       Preparer’s signature                            Date
Paid                                                                                                                                      Check          if    PTIN
                                                                                                                                          self-employed
Preparer                    ▶                                                                                                         Firm’s EIN ▶
         Firm’s name 
Use Only Firm’s address ▶                                                                                                             Phone no.
Future Developments                                     Who Must File                                         pay a penalty in lieu of arbitrage rebate. See 
                                                                                                              the instructions for line 11, later.
For the latest information about developments           Issuers of tax-exempt governmental 
related to Form 8038-GC and its instructions,           obligations with issue prices of less than            Filing a consolidated return for multiple 
such as legislation enacted after they were             $100,000 must file Form 8038-GC.                      issues. For all tax-exempt governmental 
                                                                                                              obligations with issue prices of less than 
published, go to www.irs.gov/Form8038GC.                Issuers of a tax-exempt governmental                  $100,000 that aren’t reported on a separate 
                                                        obligation with an issue price of $100,000 or         Form 8038-GC, an issuer must file a 
General Instructions                                    more must file Form 8038-G, Information               consolidated information return including all 
Section references are to the Internal Revenue          Return for Tax-Exempt Governmental Bonds.             such issues issued within the calendar year. 
Code unless otherwise noted.                            Filing a separate return for a single issue.                              Thus, an issuer may file a separate Form 
                                                        Issuers have the option to file a separate            8038-GC for each of a number of small issues 
Purpose of Form                                         Form 8038-GC for any tax-exempt                       and report the remainder of small issues 
Form 8038-GC is used by the issuers of tax-             governmental obligation with an issue price of        issued during the calendar year on one 
exempt governmental obligations to provide              less than $100,000.                                   consolidated Form 8038-GC. However, if the 
the IRS with the information required by                An issuer of a tax-exempt bond used to                issue is a construction issue, a separate Form 
section 149(e) and to monitor the                       finance construction expenditures must file a         8038-GC must be filed to give the IRS notice 
requirements of sections 141 through 150.               separate Form 8038-GC for each issue to give          of the election to pay a penalty in lieu of 
                                                        notice to the IRS that an election was made to        arbitrage rebate. 
For Paperwork Reduction Act Notice, see instructions.                                   Cat. No. 64108B                                        Form 8038-GC (Rev. 10-2021) 

Form 8038-GC (Rev. 10-2021)                                                                                                                    Page  2 
When To File                                        Definitions                                       Construction issue. This is an issue of tax-
                                                                                                      exempt bonds that meets both of the 
To file a separate return for a single issue, file  Obligations. This refers to a single tax-         following conditions: 
Form 8038-GC on or before the 15th day of           exempt governmental obligation if Form 
the 2nd calendar month after the close of the       8038-GC is used for separate reporting or to      1. At least 75% of the available 
calendar quarter in which the issue is issued.      multiple tax-exempt governmental obligations      construction  proceeds of the issue are to be 
  To file a consolidated return for multiple        if the form is used for consolidated reporting.   used for construction expenditures with 
                                                                                                      respect to property to be owned by a 
issues, file Form 8038-GC on or before              Tax-exempt obligation. This is any obligation     governmental unit or a 501(c)(3) organization, 
February 15 of the calendar year following the      including a bond, installment purchase            and 
year in which the issue is issued.                  agreement, or financial lease on which the  
Late filing. An issuer may be granted an            interest is excluded from income under            2. All of the bonds that are part of the issue 
extension of  time to file Form 8038-GC under       section 103.                                      are qualified 501(c)(3) bonds, bonds that 
                                                                                                      aren’t private activity bonds, or private activity 
section 3 of Rev. Proc. 2002-48, 2002-37            Tax-exempt governmental obligation. A                            
                                                                                                      bonds issued to finance property to be owned 
I.R.B. 531, if it is determined that the failure to tax-exempt obligation that isn’t a private                           
                                                                                                      by a governmental unit or a 501(c)(3) 
file on time isn’t due to willful neglect. Write at activity bond (see below) is a tax-exempt                                   
                                                                                                      organization. 
the top of the form, “Request for Relief under      governmental obligation. This includes a bond 
section 3 of Rev. Proc. 2002-48.” Attach to         issued by a qualified volunteer fire department   In lieu of rebating any arbitrage that may be 
the Form 8038-GC a letter briefly stating why       under section 150(e).                             owed to the United States, the issuer of a 
                                                                                                      construction issue may make an irrevocable 
the form wasn’t submitted to the IRS on time.       Private activity bond. This includes an           election to pay a penalty. The penalty is equal 
Also, indicate whether the obligation in            obligation issued as part of an issue in which:   to 1-1/2% of the amount of construction 
question is under examination by the IRS. 
Don’t submit copies of any bond documents,          • More than 10% of the proceeds are to be         proceeds that do not meet certain spending 
leases, or installment sale documents. See          used for any private activity business use, and   requirements. See section 148(f)(4)(C) and the 
Where To File next.                                 • More than 10% of the payment of principal       Instructions for Form 8038-T.
                                                    or interest of the issue is either (a) secured by 
Where To File                                       an interest in property to be used for a private  Specific Instructions 
File Form 8038-GC and any attachments at            business use (or payments for such property)      In general, a Form 8038-GC must be 
the following address.                              or (b) to be derived from payments for            completed on the basis of available 
                                                    property (or borrowed money) used for a           information and reasonable expectations as of 
  Department of the Treasury                        private business use.                             the date of issue. However, forms that are 
  Internal Revenue Service Center        
  Ogden, UT 84201                                   It also includes a bond, the proceeds of          filed on a consolidated basis may be 
                                                    which (a) are to be used to make or finance       completed on the basis of information readily  
Private delivery services (PDS). You can use        loans (other than loans described in section      available to the issuer at the close of the 
certain PDS designated by the IRS to meet           141(c)(2)) to persons other than governmental     calendar year to which the form relates, 
the “timely mailing as timely filing/paying” rule   units and (b) exceeds the lesser of 5% of the     supplemented by estimates made in good 
for tax returns and payments. These PDS             proceeds or $5 million.                           faith. 
include only the following:
• DHL Express (DHL): DHL Same Day Service.          Issue. Generally, obligations are treated as 
                                                    part of the same issue only if they are issued    Part I—Reporting Authority 
• Federal Express (FedEx): FedEx Priority           by the same issuer, on the same date, and as      Amended return. An issuer may file an 
Overnight, FedEx Standard Overnight, FedEx          part of a single transaction, or a series of      amended return to change or add to the 
2Day, FedEx International Priority, and FedEx       related transactions. However, obligations        information reported on a previously filed 
International First.                                issued during the same calendar year (a)          return for the same date of issue. If you are 
• United Parcel Service (UPS): UPS Next Day         under a loan agreement under which amounts        filing to correct errors or change a previously 
Air, UPS Next Day Air Saver, UPS 2nd Day            are to be advanced periodically (a “draw-         filed return, check the Amended Return box in 
Air, UPS 2nd Day Air A.M., UPS Worldwide            down loan”) or (b) with a term not exceeding      the heading of the form. 
Express Plus, and UPS Worldwide Express.            270 days, may be treated as part of the same      The amended return must provide all the  
                                                    issue if the obligations are equally and ratably  information reported on the original return, in  
  The PDS can tell you how to get written           secured under a single indenture or loan          addition to the new corrected information. 
proof of the mailing date.                          agreement and are issued under a common           Attach an explanation of the reason for the 
Other Forms That May Be                             financing arrangement (for example, under the     amended return and write across the top 
                                                    same official statement periodically updated      “Amended Return Explanation.”
Required                                            to reflect changing factual circumstances). 
For rebating arbitrage (or paying a penalty in      Also, for obligations issued under a draw-        Line 1. The issuer’s name is the name of the 
lieu of arbitrage rebate) to the federal            down loan that meets the requirements of the      entity issuing the obligations, not the name of 
government, use Form 8038-T, Arbitrage              preceding sentence, obligations issued during     the entity receiving the benefit of the 
Rebate, Yield Reduction and Penalty in Lieu         different calendar years may be treated as        financing. In the case of a lease or installment 
of Arbitrage Rebate. For private activity           part of the same issue if all of the amounts to   sale, the issuer is the lessee or purchaser. 
bonds, use Form 8038, Information Return for        be advanced under the draw-down loan are          Line 2. An issuer that doesn’t have an 
Tax-Exempt Private Activity Bond Issues.            reasonably expected to be advanced within 3       employer identification number (EIN) should 
  For a tax-exempt governmental obligation          years of the date of issue of the first           apply for one online by visiting the IRS 
with an issue price of $100,000 or more, use        obligation. Likewise, obligations (other than     website at www.irs.gov/EIN. The organization 
Form 8038-G.                                        private activity bonds) issued under a single     may also apply for an EIN by faxing or mailing 
                                                    agreement that is in the form of a lease or       Form SS-4 to the IRS.
Rounding to Whole Dollars                           installment sale may be treated as part of the    Lines 3 and 4. Enter the issuer’s address or 
                                                    same issue if all of the property covered by      the address of the designated contact person 
You may show the money items on this return         that agreement is reasonably expected to be       listed on line 6. If the issuer wishes to use its 
as whole-dollar amounts. To do so, drop any         delivered within 3 years of the date of issue of  own address and the issuer receives its mail 
amount less than 50 cents and increase any          the first obligation.                             in care of a third party authorized 
amount from 50 to 99 cents to the next higher 
dollar. For example, $1.49 becomes $1 and           Arbitrage rebate. Generally, interest on a        representative (such as an accountant or 
$2.50 becomes $3. If two or more amounts            state or local bond isn’t tax-exempt unless       attorney), enter on the street address line    
must be added to figure the amount to enter         the issuer of the bond rebates to the United      “C/O” followed by the third party’s name and  
on a line, include cents when adding the            States arbitrage profits earned from investing    street address or P.O. box. Include the suite, 
amounts and round off only the total.               proceeds of the bond in higher yielding           room, or other unit number after the street 
                                                    nonpurpose investments. See section 148(f).       address. If the post office doesn’t deliver  

Form 8038-GC (Rev. 10-2021)                                                                                                                 Page  3 

mail to the street address and the issuer has a  purchase. For line 9d, enter the type of item     Paid Preparer 
P.O. box, show the box number instead of the     that is leased. For lines 9e through 9h, enter 
street address. If a change in address occurs    the amount on the appropriate line that           If an authorized representative of the issuer 
after the return is filed, use Form 8822,        represents a bank loan. For line 9h, enter the    filled in its return, the paid preparer’s space 
Change of Address, to notify the IRS of the      type of bank loan.                                should remain blank. Anyone who prepares 
                                                                                                   the return but does not charge the 
new address.                                     Lines 9i and 9j. For line 9i, enter the amount    organization shouldn’t sign the return. Certain 
Note: The address entered on lines 3 and 4 is    of the proceeds that will be used to pay          others who prepare the return shouldn’t sign. 
the address the IRS will use for all written     principal, interest, or call premium on any       For example, a regular, full-time employee of 
communications regarding the processing of       other issue of bonds, including proceeds that     the issuer, such as a clerk, secretary, etc., 
this return, including any notices. By           will be used to fund an escrow account for        shouldn’t sign.
authorizing a person other than an authorized    this purpose. Several lines may apply to a 
officer or other employee of the issuer to       particular obligation. For example, report on       Generally, anyone who is paid to prepare a 
communicate with the IRS and whom the IRS        lines 9i and 9j obligations used to refund prior  return must sign it and fill in the other blanks 
may contact about this return, the issuer        issues which represent loans from the             in the Paid Preparer Use Only area of the 
authorizes the IRS to communicate directly       proceeds of another tax-exempt obligation.        return. A paid preparer cannot use a social 
                                                                                                   security number in the Paid Preparer Use Only 
with the individual listed on line 6, whose      Line 9k. Enter on line 9k the amount on line      box. The paid preparer must use a preparer 
address is entered on lines 3 and 4 and          8a that doesn’t represent an obligation           tax identification number (PTIN). If the paid 
consents to disclose the issuer’s return         described on lines 9a through 9j.                 preparer is self-employed, the preparer 
information to that individual, as necessary, to 
process this return.                             Line 10. Check this box if the issuer has         should enter his or her address in the box.
                                                 designated any issue as a “small issuer             The paid preparer must:
Line 5. This line is for IRS use only. Don’t     exception” under section 265(b)(3)(B)(i)(III). 
make any entries in this box.                                                                      • Sign the return in the space provided for the 
                                                 Line 11. Check this box if the issue is a         preparer’s signature, and
Part II—Description of Obligations               construction issue and an irrevocable election    • Give a copy of the return to the issuer. 
                                                 to pay a penalty in lieu of arbitrage rebate has 
Check the appropriate box designating this as    been made on or before the date the bonds 
a return on a single issue basis or a            were issued. The penalty is payable with a        Paperwork Reduction Act Notice 
consolidated return basis.                       Form 8038-T for each 6-month period after         We ask for the information on this form to 
Line 8a. The issue price of obligations is       the date the bonds are issued. Don’t make         carry out the Internal Revenue laws of the 
generally determined under Regulations           any payment of penalty in lieu of rebate with     United States. You are required to give us the 
section 1.148-1(b). Thus, when issued for        Form  8038-GC. See Rev. Proc. 92-22,              information. We need it to ensure that you are 
cash, the issue price is the price at which a    1992-1 C.B. 736, for rules regarding the          complying with these laws. 
substantial amount of the obligations are sold   “election document.” 
                                                                                                     You are not required to provide the 
to the public. To determine the issue price of   Line 12. Enter the name of the vendor or bank     information requested on a form that is 
an obligation issued for property, see sections  who is a party to the installment purchase        subject to the Paperwork Reduction Act 
1273 and 1274 and the related regulations.       agreement, loan, or financial lease. If there are unless the form displays a valid OMB control 
Line 8b. For a single issue, enter the date of   multiple vendors or banks, the issuer should      number. Books or records relating to a form  
issue (for example, 03/15/2020 for a single      attach a schedule.                                or its instructions must be retained as long as 
issue issued on March 15, 2020), generally       Line 13. Enter the employer identification        their contents may become material in the 
the date on which the issuer physically          number of the vendor or bank who is a party       administration of any Internal Revenue law. 
exchanges the bonds that are part of the         to the installment purchase agreement, loan,      Generally, tax returns and return information 
issue for the underwriter’s (or other            or financial lease. If there are multiple vendors are confidential, as required by section 6103. 
purchaser’s) funds; for a lease or installment   or banks, the issuer should attach a schedule.      The time needed to complete and file this 
sale, enter the date interest starts to accrue. 
                                                                                                   form will vary depending on individual 
For issues reported on a consolidated basis,     Signature and Consent                             circumstances. The estimated burden for tax 
enter the first day of the calendar year during 
which the obligations were issued (for           An authorized representative of the issuer        exempt organizations filing this form is 
example, for calendar year 2020, enter           must sign Form 8038-GC and any applicable         approved under OMB control number 
01/01/2020).                                     certification. Also, write the name and title of  1545-0047 and is included in the estimates 
                                                 the person signing Form 8038-GC. The              shown in the instructions for their information 
Lines 9a through 9h. Complete this section if    authorized representative of the issuer signing   return.
property other than cash is exchanged for the    this form must have the authority to consent        If you have suggestions for making this 
obligation, for example, acquiring a police car, to the disclosure of the issuer’s return          form simpler, we would be happy to hear from 
a fire truck, or telephone equipment through a   information, as necessary to process this         you. You can send us comments through 
series of monthly payments. (This type of        return, to the person(s) that has been            www.irs.gov/FormComments. Or you can 
obligation is sometimes referred to as a         designated in this form.                          write to:
“municipal lease.”) Also, complete this section 
if real property is directly acquired in         Note: If the issuer authorizes on line 6 the IRS    Internal Revenue Service                          
exchange for an obligation to make periodic      to communicate with a person other than an          Tax Forms and Publications                   
payments of interest and principal.              officer or other employee of the issuer (such       1111 Constitution Ave. NW, IR-6526 
                                                 authorization shall include contact both in         Washington, DC 20224
Don’t complete lines 9a through 9d if the        writing regardless of the address entered on 
proceeds of an obligation are received in the    lines 3 and 4, and by telephone), by signing        Do not send Form 8038-GC to this 
form of cash even if the term “lease” is used    this form, the issuer’s authorized                address. Instead, see Where To File, earlier.
in the title of the issue. For lines 9a through  representative consents to the disclosure of 
9d, enter the amount on the appropriate line     the issuer’s return information, as necessary 
that represents a lease or installment           to process this return, to such person.