HomeMy WebLinkAboutA027 - IRS Form 8038-G 418663-42
Form 8038-G Information Return for Tax-Exempt Governmental Obligations
(Rev.September 2011) ►Under Internal Revenue Code section 149(e) OMB No.1545-0720
Department of the Treasury ►See separate instructions.
Internal Revenue Service Caution:It the issue price is under$100,000,use Form 8038-GC.
Riporting Authority If Amended Return,check here ► ❑
1 Issuer's name 2 Issuer's employer identification number(EIN)
City of Ames,Iowa 42-6004218
3a Name of person(other than issuer)with whom the IRS may communicate about this return(see instructions) 3b Telephone number of other person shown on 3a
4 Number and street(or P.O.box if mail is not delivered to street address) RooMsuite 5 Report number(For IRS Use Only)
515 Clark Avenue 13
6 City,town,or post office,state,and ZIP code 7 Date of issue
Ames,Iowa 50010 October 25,2011
8 Name of issue 9 CUSIP number
Hospital Revenue Bonds(Mary Greeley Medical Center),Series 2011 030850 ER8
108 Name and title of officer or other employee of the issuer whom the IRS may call for more information(see 10b Telephone number of officer or other
instructions) employee shown on 10a
Diane R.Voss,City Clerk 515-239-5105
Type of Issue(enter the issue price). See the instructions and attach schedule.
11 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Health and hospital . . . . . . . . . . . . . . . . . . . . . . . . . . 12 65,716,598
13 Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Public safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Environment(including sewage bonds) . . . . . . . . . . . . . . . . . . . . 15
16 Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Utilities . . . . . . . . .. . . . . . . . ' 17
18 Other. Describe No 18
:,
19 If obligations are TANS or RANs,check only box 19a ' . ► ❑
If obligations are BANS,check only box 19b ► ❑
20 If obligations are in the form of a lease or install a ck box . . . . . ► ❑ � ;
Description of Obligati ns.Complete f the entire issue for which this form is being filed.
(a)Final maturity date (b)Issue price (c)Stated redemption (d)Weighted (a)Yield
price at maturity average maturity
21 6/15/2036 65,716,598 65,000,000 17.901 vears 5.1269 /e
111 Uses of Proceeds of Bond Issue(including underwriters'discount)
22 Proceeds used for accrued interest . . . . . . . . . . . . . . . . . . . . . 22
23 Issue price of entire issue(enter amount from line 21,column(b)) . . . . . 23 65,716,598
41-011
24 Proceeds used for bond issuance costs(including underwriters'discount). 24 731,260 =M
25 Proceeds used for credit enhancement . . . . . . . . . . . . 25 n'
26 Proceeds allocated to reasonably required reserve or replacement fund 26
27 Proceeds used to currently refund prior issues . . . . . . . . . 27
28 Proceeds used to advance refund prior issues . . . . . . . . . 28 °
29 Total(add lines 24 through 28) . . . . . . . . . . . . . . . . . . . . . . . 29 731,250
30 Nonrefunding proceeds of the issue(subtract line 29 from line 23 and enter amount here) 30 1 64,985,348
Description of Refunded Bonds.Complete this part only for refunding bonds.
31 Enter the remaining weighted average maturity of the bonds to be currently refunded . . . . ► years
32 Enter the remaining weighted average maturity of the bonds to be advance refunded . . . . ► years
33 Enter the last date on which the refunded bonds will be called(MM/DD/YYY`l) . . . . . . ►
34 Enter the date(s)the refunded bonds were issued►(MM/DD/YYYY)
For Paperwork Reduction Act Notice,see separate instructions. Cat.No.63773S Form 8038-G(Rev.9-2011)
Form 8038-G(Rev.9-2011) Page 2
Miscellaneous
35 Enter the amount of the state volume cap allocated to the issue under section 141(b)(5) . . . 35
36a Enter the amount of gross proceeds invested or to be invested in a guaranteed investment contract a;
(GIC)(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . 36a
b Enter the final maturity date of the GIC►
c Enter the name of the GIC provider►
37 Pooled financings: Enter the amount of the proceeds of this issue that are to be used to make loans
to other governmental units . . . . . . . . . . . . . . . . . . 37
38a If this issue is a loan made from the proceeds of another tax-exempt issue,check box► ❑and enter the following information:
b Enter the date of the master pool obligation No-
e Enter the EIN of the issuer of the master pool obligation Ol-
d Enter the name of the issuer of the master pool obligation►
39 If the issuer has designated the issue under section 265(b)(3)(B)(i)(III)(small issuer exception),check box . . . . ► ❑
40 If the issuer has elected to pay a penalty in lieu of arbitrage rebate,check box . . . . . . . . . . . . . ► ❑
41a If the issuer has identified a hedge,check here► ❑ and enter the following information:
b Name of hedge provider Do-
c Type of hedge Po-
d Term of hedge►
42 If the issuer has superintegrated the hedge,check box . . . . . . . . . . . . . . . . . . ► ❑
43 If the issuer has established written procedures to ens^, that all nonqualified bonds of this issue are remediated
according to the requirements under the Code and Re,�gt6I tiorls(see instructions),check box . . . . . . . . ► ❑✓
44 If the issuer has established written procedures to and it6>t`Me requirements of section 148,check box . . . . . ► ❑✓
45a If some portion of the proceeds was used to reire6wrse`ftenditures,check here► ❑✓ and enter the amount
of reimbursement . . . . . . . e��► '. ' $3,000,000
b Enter the date the official intent was ado W i� ugust 9,2011
Under penalties of perjury,I declare that I have examined this return and accompanying schedules and statements,and to the best of my knowledge
Signature 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
and rocess thr;re rn,'to the that I ve authorized above. v
Consent Diane R.Voss,City Clerk
F—StgrVature of issuer's authorized representative Date 'Type or print name and title
PrintfType preparer's name Preparer's signature Date PTIN
Paid Check ❑ if
Preparer Cristina Kuhn I self-employed P01067129
Use Only Firm's name ► Dorsey&Whitney LLP Firm's EIN ► 41-0223337
Firm's address ► 801 Grand Avenue,Suite 3900,Des Moines,Iowa 50309 Phone no. 515-283-1000
Form 803&G(Rev.9-2011)