Form 8038-CP
(Rev. January 2012)
Department of the Treasury
Internal Revenue Service
Return for Credit Payments
to Issuers of Qualified Bonds
OMB No. 1545-2142
Part I
Information on Entity That Is To Receive Payment of Credit and Communications
Check box if Amended Return
1
Name of entity that is to receive payment of the credit
2
Employer identification number (EIN)
3
Number and street (or P.O. box no. if mail is not delivered to street address) Room/suite
4
City, town, or post office, state, and ZIP code
5
Name and title of designated contact person whom the IRS may call for more information
6
Telephone number of officer or legal representative
Part II Reporting Authority
7
Issuer’s name (if same as line 1, enter “SAME” and skip lines 8, 9, 11, 15, and 16)
8
EIN
9
Number and street (or P.O. box no. if mail is not delivered to street address) Room/suite
10
Report number (For IRS Use Only)
11
City, town, or post office, state, and ZIP code
12
Date of issue (MM/DD/YYYY)
13
Name of issue
14
CUSIP number (see instructions)
15
Name and title of officer or other person whom the IRS may call for more information
16
Telephone number of officer or other person to call
17a
Type of issue
For build America bonds and recovery zone economic development bonds, check the applicable box (see instructions)
Educational Health and Hospital Transportation Public Safety Environmental Housing Utilities Other
b
For build America bonds, recovery zone economic development bonds, and specified tax credit bonds, enter
the issue price . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17b
c
Check applicable box
Variable rate bond Fixed rate bond
Part III Payment of Credit (For specified tax credit bonds with multiple maturities, see instructions.)
18 Interest payment date to which this payment of credit relates (MM/DD/YYYY)
19a Interest payable to bondholders on the interest payment date . . . . . . . . . . . . . . . 19a
b
For specified tax credit bonds only, enter the applicable credit rate determined under Sec. 54A(b)(3)
.
%
c
For specified tax credit bonds only, enter the interest that would be payable to bondholders on the interest
payment date calculated using the applicable credit rate (see instructions) . . . . . . . . . . .
19c
20
Amount of credit payment to be received as of the interest payment date (complete only line 20a, 20b, 20c, 20d, 20e, or 20f)
a Build America bonds. Multiply line 19a by 35% . . . . . . . . . . . . . . . . . . . 20a
b Recovery zone economic development bonds. Multiply line 19a by 45% . . . . . . . . . . . . 20b
c New clean renewable energy bonds enter the lesser of line 19a or 70% of line 19c . . . . . . . . . 20c
d Qualified energy conservation bonds enter the lesser of line 19a or 70% of line 19c . . . . . . . . 20d
e Qualified zone academy bonds enter the lesser of lines 19a or 19c . . . . . . . . . . . . . 20e
f Qualified school construction bonds enter the lesser of lines 19a or 19c . . . . . . . . . . . . 20f
21 Adjustment to previous credit payments (complete line 21a OR line 21b only):
a Net increase to previous payments (attach explanation) . . . . . . . . . . . . . . . . . 21a
b Net decrease to previous payments (attach explanation) . . . . . . . . . . . . . . . . 21b
22
Amount of credit payment to be received. Combine either line 20a, 20b, 20c, 20d, 20e, or 20f with line 21a or line 21b .
22
23 Is this the final interest payment date? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
24
If the entity identified in Part I is not the issuer, check this box . . . . . . . . . . . . . . . . . . . . . .
Direct
Deposit
25 Enter direct deposit information below:
a Routing number
b Type:
Checking Savings
c Account number
Signature
and
Consent
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 authorize the IRS to send the requested refundable credit payment to the entity
identified in Part I, and I consent to the disclosure of the issuer’s return information, as necessary to process the refundable credit payment, to the
designated contact person(s) listed above in Parts I and II, as applicable.
Signature of issuer
Date
Type or print name and title
Paid
Preparer
Use Only
Print/Type preparer’s name Preparer's signature Date
Check if
self-employed
PTIN
Firm’s name
Firm's address
Firm's EIN
Phone no.
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 52810E
Form 8038-CP (Rev. 1-2012)
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