Information Return for Small Tax-Exempt   
Form  8038-GC
(Rev. January 2012)             Governmental Bond Issues, Leases, and Installment Sales                                                                 OMB No. 1545-0720 
                                                       ▶
Department of the Treasury                                 Under Internal Revenue Code section 149(e) 
Internal Revenue Service             Caution: If the issue price of the issue is $100,000 or more, use Form 8038-G. 
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 is not 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: 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:
             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) 
Signature    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                                            PTIN
Paid                                                                                                                                       Check         if 
                                                                                                                                           self-employed
Preparer 
Use Only     Firm’s name      ▶                                                                                                        Firm's EIN  ▶
             Firm's address  ▶                                                                                                         Phone no.
General Instructions                                     Who Must File                                           pay a penalty in lieu of arbitrage rebate (see 
Section references are to the Internal Revenue           Issuers of tax-exempt governmental                      the line 11 instructions).  
Code unless otherwise noted.                             obligations with  issue prices of less than             Filing a consolidated return for multiple 
                                                         $100,000 must file Form  8038-GC.                       issues. For all tax-exempt governmental 
What's New                                               Issuers of a tax-exempt governmental                    obligations with issue prices of less than 
The IRS has created a page on IRS.gov for                obligation  with an issue price of $100,000 or          $100,000 that are not reported on a separate 
information about the Form 8038 series and               more must file Form 8038-G, Information                 Form 8038-GC, an issuer must file a 
its instructions, at www.irs.gov/form8038.               Return for Tax-Exempt Governmental                      consolidated information return including all 
Information about any future developments                Obligations.                                            such issues issued within the calendar year. 
affecting the Form 8038 series (such as                  Filing a separate return for a single issue.                              Thus, an issuer may file a separate Form 
legislation enacted after we release it) will be         Issuers  have the option to file a separate             8038-GC for each of a number of small issues 
posted on that page.                                     Form 8038-GC for any tax-exempt                         and report the remainder of small issues 
Purpose of Form                                          governmental obligation with an  issue price            issued during the calendar year on one 
                                                         of less than $100,000.                                  consolidated Form 8038-GC. However, if the 
Form 8038-GC is used by the issuers of tax-                                                                      issue is a construction issue, a separate Form 
exempt  governmental obligations to provide              An issuer of a tax-exempt bond used to                  8038-GC must be filed to give the IRS notice 
the IRS with the  information required by                finance construction expenditures must file a           of the election to pay a penalty in lieu of 
section 149(e) and to monitor the                        separate Form 8038-GC for each issue to give            arbitrage rebate. 
requirements of sections 141 through 150.                notice to the IRS that an election was made to 

                                                                                 Cat. No. 64108B                                                Form  8038-GC  (Rev. 1-2012)

Form 8038-GC (Rev. 1-2012)                                                                                                                    Page  2 
When To File                                        multiple tax-exempt governmental obligations      1. At least 75% of the available construction 
                                                    if the form is used for consolidated reporting.   proceeds of the issue are to be used for 
To file a separate return for a single issue, file                                                    construction expenditures with respect to 
Form 8038-GC on or before the 15th day of           Tax-exempt obligation. This is any obligation 
the second calendar month after the close of        including a bond, installment purchase            property to be owned by a governmental unit 
the calendar quarter in which the issue is          agreement, or financial lease, on which the       or a 501(c)(3) organization, and 
issued.                                             interest is excluded from income under            2. All of the bonds that are part of the issue 
                                                    section 103.                                      are qualified 501(c)(3) bonds, bonds that are 
  To file a consolidated return for multiple                                                          not private activity bonds, or private activity 
issues, file Form 8038-GC on or before              Tax-exempt governmental obligation. A 
February 15th of the calendar year following        tax-exempt obligation that is not a private       bonds issued to finance property to be owned 
the year in which the issue is issued.              activity bond (see below) is a tax-exempt         by a governmental unit or a 501(c)(3) 
                                                    governmental obligation. This includes a bond     organization. 
Late filing. An issuer may be granted an            issued by a qualified volunteer fire department   In lieu of rebating any arbitrage that may be 
extension of  time to file Form 8038-GC under       under section 150(e).                             owed to the United States, the issuer of a 
section 3 of Rev. Proc. 2002-48, 2002-37 
I.R.B. 531, if it is determined that the failure to Private activity bond. This includes an           construction issue may make an irrevocable 
file on time is not due to willful neglect. Type    obligation issued as part of an issue in which:   election to pay a penalty. The penalty is equal 
                                                                                                      to 1-1/2% of the amount of construction 
or print at the top of the form, “Request for       • More than 10% of the proceeds are to be         proceeds that do not meet certain spending 
Relief under section 3 of Rev. Proc. 2002-48.”      used for any private activity business use, and   requirements. See section 148(f)(4)(C) and the 
Attach to the Form 8038-GC a letter briefly 
stating why the form was not submitted to the       • More than 10% of the payment of principal       Instructions for Form 8038-T.
IRS on time. Also indicate whether the              or interest of the issue is either (a) secured by 
obligation in question is under examination by      an interest in property to be used for a private  Specific Instructions 
the IRS. Do not submit copies of any bond           business use (or payments for such property)      In general, a Form 8038-GC must be 
documents, leases, or installment sale              or (b) to be derived from payments for            completed on the basis of available 
documents. See Where To File next.                  property (or borrowed money) used for a           information and reasonable expectations as of 
                                                    private business use.                             the date of issue. However, forms that are 
Where To File                                       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  
File Form 8038-GC, and any attachments,             loans (other than loans described in section      available to the issuer at the close of the 
with the Department of the Treasury, Internal       141(c)(2)) to persons other than governmental     calendar year to which the form relates, 
Revenue Service Center, Ogden, UT 84201.            units and (b) exceeds the lesser of 5% of the     supplemented by estimates made in good 
Private delivery services. You can use              proceeds or $5 million.                           faith. 
certain private delivery services designated by     Issue. Generally, obligations are treated as      Part I—Reporting Authority 
the IRS to meet the “timely mailing as timely       part of the same issue only if they are issued 
filing/paying” rule for tax returns and             by the same issuer, on the same date, and as      Amended return. An issuer may file an 
payments. These private delivery services           part of a single transaction, or a series of      amended return to change or add to the 
include only the following:                         related transactions. However, obligations        information reported on a previously filed 
• DHL Express (DHL): DHL Same Day Service.          issued during the same calendar year (a)          return for the same date of issue. If you are 
• Federal Express (FedEx): FedEx Priority           under a loan agreement under which amounts        filing to correct errors or change a previously 
Overnight, FedEx Standard Overnight, FedEx          are to be advanced periodically (a “draw-         filed return, check the “Amended Return” box 
2Day, FedEx International Priority, and FedEx       down loan”) or (b) with a term not exceeding      in the heading of the form. 
International First.                                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  
• United Parcel Service (UPS): UPS Next Day         secured under a single indenture or loan          addition to the new corrected information. 
Air, UPS Next Day Air Saver, UPS 2nd Day            agreement and are issued under a common           Attach an explanation of the reason for the 
Air, UPS 2nd Day Air A.M., UPS Worldwide            financing arrangement (for example, under the     amended return and write across the top 
Express Plus, and UPS Worldwide Express.            same official statement periodically updated      "Amended Return Explanation."
  The private delivery service can tell you         to reflect changing factual circumstances).       Line 1. The issuer’s name is the name of the 
how to get written proof of the mailing date.       Also, for obligations issued under a draw-        entity issuing the obligations, not the name of 
                                                    down loan that meets the requirements of the 
Other Forms That May Be                             preceding sentence, obligations issued during     the entity receiving the benefit of the 
Required                                            different calendar years may be treated as        financing. In the case of a lease or installment 
                                                    part of the same issue if all of the amounts to   sale, the issuer is the lessee or purchaser. 
For rebating arbitrage (or paying a penalty in      be advanced under the draw-down loan are          Line 2. An issuer that does not have an 
lieu of  arbitrage rebate) to the Federal           reasonably expected to be advanced within 3       employer identification number (EIN) should 
Government, use Form 8038-T, Arbitrage              years of the date of issue of the first           apply for one on Form SS-4, Application for 
Rebate, Yield Reduction and Penalty in Lieu         obligation. Likewise, obligations (other than     Employer Identification Number. You can get 
of Arbitrage Rebate. For private activity           private activity bonds) issued under a single     this form on the IRS website at IRS.gov or by 
bonds, use Form 8038, Information Return for        agreement that is in the form of a lease or       calling 1-800-TAX-FORM (1-800-829-3676). 
Tax-Exempt Private Activity Bond Issues.            installment sale may be treated as part of the    You may receive an EIN by telephone by 
  For a tax-exempt governmental obligation          same issue if all of the property covered by      following the instructions for Form SS-4. 
with an issue price of $100,000 or more, use        that agreement is reasonably expected to be       Lines 3 and 4. Enter the issuer’s address or 
Form 8038-G.                                        delivered within 3 years of the date of issue of  the address of the designated contact person 
                                                    the first obligation.                             listed on line 6. If the issuer wishes to use its 
Rounding to Whole Dollars                           Arbitrage rebate. Generally, interest on a        own address and the issuer receives its mail 
You may show the money items on this return         state or local bond is not tax-exempt unless      in care of a third party authorized 
as whole-dollar amounts. To do so, drop any         the issuer of the bond rebates to the United      representative (such as an accountant or 
amount less than 50 cents and increase any          States arbitrage profits earned from investing    attorney), enter on the street address line    
amount from 50 to 99 cents to the next higher       proceeds of the bond in higher yielding           “C/O” followed by the third party's name and 
dollar.                                             nonpurpose investments. See section 148(f).       street address or P.O. box. Include the suite, 
                                                    Construction issue. This is an issue of tax-      room, or other unit number after the street 
Definitions                                         exempt bonds that meets both of the               address. If the post office does not deliver 
Obligations. This refers to a single tax-           following conditions:                             mail to the street address and the issuer has a 
                                                                                                      P.O. box, show the box number instead of the 
exempt governmental obligation if Form 
8038-GC is used for separate reporting or to

Form 8038-GC (Rev. 1-2012)                                                                                                                       Page  3 

street address. If a change in address occurs    Lines 9i and 9j. For line 9i, enter the amount    Paid Preparer 
after the return is filed, use Form 8822,        of the proceeds that will be used to pay 
Change of Address, to notify the IRS of the      principal, interest, or call premium on any       If an authorized representative of the issuer 
new address.                                     other issue of bonds, including proceeds that     filled in its return, the paid preparer’s space 
                                                 will be used to fund an escrow account for        should remain blank. Anyone who prepares 
Note. The address entered on lines 3 and 4 is    this purpose. Several lines may apply to a        the return but does not charge the 
the address the IRS will use for all written     particular obligation. For example, report  on    organization should not sign the return. 
communications regarding the processing of       lines 9i and 9j obligations used to refund prior  Certain others who prepare the return should 
this return, including any notices. By           issues which represent loans from the             not sign. For example, a regular, full-time 
authorizing a person other than an authorized    proceeds of another tax-exempt obligation.        employee of the issuer, such as a clerk, 
                                                                                                   secretary, etc., should not sign.
officer or other employee of the issuer to       Line 9k. Enter on line 9k the amount on line 
communicate with the IRS and whom the IRS        8a that does not represent an obligation          Generally, anyone who is paid to prepare a 
may contact about this return, the issuer        described on lines 9a through 9j.                 return must sign it and fill in the other blanks 
authorizes the IRS to communicate directly                                                         in the Paid Preparer Use Only area of the 
with the individual listed on line 6, whose      Line 10. Check this box if the issuer has         return. A paid preparer cannot use a social 
address is entered on lines 3 and 4 and          designated any issue as a “small issuer           security number in the Paid Preparer Use Only 
consents to disclose the issuer's return         exception” under section 265(b)(3)(B)(i)(III).    box. The paid preparer must use a preparer 
information to that individual, as necessary, to Line 11. Check this box if the issue is a         tax identification number (PTIN). If the paid 
process this return.                             construction issue and an irrevocable election    preparer is self-employed, the preparer 
Line 5. This line is for IRS use only. Do not    to pay a penalty in lieu of arbitrage rebate has  should enter his or her address in the box.
make any entries in this box.                    been made on or before the date the bonds         The paid preparer must:
                                                 were issued. The penalty is payable with a        • Sign the return in the space provided for the 
Part II—Description of Obligations               Form 8038-T for each 6-month period after         preparer’s signature, and
                                                 the date the bonds are issued. Do not make 
Check the appropriate box designating this as    any payment of penalty in lieu of rebate with     • Give a copy of the return to the issuer. 
a return on a single issue basis or a            Form  8038-GC. See Rev. Proc. 92-22, 
consolidated return basis.                       1992-1 C.B. 736, for rules regarding the          Paperwork Reduction Act Notice 
Line 8a. The issue price of obligations is       “election document.” 
                                                                                                   We ask for the information on this form to 
generally determined under Regulations           Line 12. Enter the name of the vendor or bank     carry out the Internal Revenue laws of the 
section 1.148-1(b). Thus, when issued for        who  is a party to the installment purchase       United States. You are required to give us the 
cash, the issue price is the  price at which a   agreement,  loan, or financial lease. If there    information. We need it to ensure that you are 
substantial amount of the obligations  are sold  are multiple vendors or banks, the issuer         complying with these laws. 
to the public. To determine the issue price of   should attach a schedule. 
an obligation issued for property, see sections                                                    You are not required to provide the 
1273 and 1274 and the related regulations.       Line 13. Enter the employer identification        information requested on a form that is 
                                                 number of the vendor or bank who is a party       subject to the Paperwork Reduction Act 
Line 8b. For a single issue, enter the date of   to the installment purchase agreement, loan,      unless the form displays a valid OMB control 
issue (for example, 03/15/2010 for a single      or financial lease. If there are multiple vendors number. Books or records relating to a form  
issue issued on March 15, 2010), generally       or banks, the issuer should attach a schedule.    or its instructions must be retained as long as 
the date on which the issuer physically                                                            their contents may become material in the 
exchanges the bonds that are part of the         Signature and Consent                             administration of any Internal Revenue law. 
issue for the underwriter’s (or other 
purchaser’s) funds; for a lease or installment   An authorized representative of the issuer        Generally, tax returns and return information 
sale, enter the date interest starts to accrue.  must sign Form 8038-GC and any applicable         are confidential, as required by section 6103. 
For issues reported on a consolidated basis,     certification. Also print the name and title of   The time needed to complete and file this 
enter the first day of the calendar year during  the person signing Form 8038-GC. The              form will vary depending on individual 
which the obligations were issued (for           authorized representative of the issuer signing   circumstances. The estimated average time is:
example, for calendar year 2010, enter           this form must have the authority to consent 
01/01/2010).                                     to the disclosure of the issuer's return          Learning about the                                     
                                                 information, as necessary to process this         law or the form       .   .     .   .  4 hr., 46 min.
Lines 9a through 9h. Complete this section if    return, to the person(s) that has been            Preparing the form        . . . . 2 hr., 22 min.
property other than cash is exchanged for the    designated in this form.
obligation, for example, acquiring a police car,                                                   Copying, assembling, and                 
a fire truck, or telephone equipment through a   Note. If the issuer authorizes in line 6 the IRS  sending the form to the IRS         . 2  hr., 34 min.
series of monthly payments. (This type of        to communicate with a person other than an 
obligation is sometimes referred to as a         officer or other employee of the issuer, (such    If you have comments concerning the 
“municipal lease.”) Also complete this section   authorization shall include contact both in       accuracy of  these time estimates or 
if real property is directly acquired in         writing regardless of the address entered in      suggestions for making this form simpler, we 
exchange for an obligation to make periodic      lines 3 and 4, and by telephone) by signing       would be happy to hear from you. You can 
payments of interest and principal.              this form, the issuer's authorized                write to the Internal Revenue Service, Tax  
                                                 representative consents to the disclosure of      Products Coordinating Committee,  
  Do not complete lines 9a through 9d if the     the issuer's return information, as necessary     SE:W:CAR:MP:T:M:S, 1111 Constitution Ave. 
proceeds of an obligation are received in the    to process this return, to such person.           NW, IR-6526, Washington, DC 20224. Do not 
form of cash even if the term “lease” is used                                                      send the form to this address. Instead, see 
in the title of the issue. For lines 9a through                                                    Where To File. 
9d, enter the amount on the appropriate line 
that represents a lease or installment 
purchase. For line 9d, enter the type of item 
that is leased. For lines 9e through 9h, enter 
the amount on the appropriate line that 
represents a bank loan. For line 9h, enter the 
type of bank loan.