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BILLING INFORMATIOH <br /> PLEASE COMPLETE THIS FORM AND RETURN WITH DOCUMENTS <br /> In order for DE LAGE LANDEN PUBLIC FINANCE LLC to properly bill and credit your account, it is necessary that you <br /> complete this form and return it with the signed documents. <br /> Billing Name: <br /> Would you like your invoices emailed to you? �jj YES ❑NO <br /> Email Address(es):— T c 1 a r k�d e c a t u r i�. g^�• <br /> 'YOUR INVOICES WILL BE EMAILED FROM INVOICEDELIVERY�LEASEDIHECT.COM <br /> Billing Address: �,���?�� � �}�4e�'S 9�3 ��.�^ <br /> De _a i�,; IT. fi752� <br /> Attention: G r P g.g n_ 7 l P Tl r A 7"A <br /> Telephone tVumber: 217 4 2 4 2 7 0 2 <br /> FEDERAL ID#: 37-6001308 <br /> SPEGIAL INSTRUCTIONS <br /> Do you require a Purchase Order Number on the invoice?If so,please aflach a copy of the purchase order(frani&6ack)for our file. ❑YES ($NO <br /> Is a new purchase order required tor each new fiscal period? ❑YES I$NO <br /> If yes,provide month/year PO expires <br /> Do you have multiple contracts,and would like them all billed on one invoice(Summary Billing)? ❑YES � <br /> Are you tax exempY?It yea,please ariach a copy of exempt certificaie or direct pay permit. � ❑NO <br /> Do you require any special information to estahlish a vendor n�mber for ? ❑YES f�'N <br /> If yes,please advise: <br /> Additional Comments: <br /> Would you prefer the same billing date for all Contracts? ❑YES �N <br /> CONTACT INFORMATION AND QUESTIONNAIRE FOR FORM 8038-G fILINGS <br /> ContactName: GTeQQ D. Zientara <br /> Tit�e: City Treasurer & Director of Finance <br /> ny� Gary n erson aza Decatur, L 62523 <br /> Contact Address: <br /> Contact Telephone Number: 21 Z �.S.n—2?�6 <br /> EmailAddress: gzientara�decaturil,gov <br /> Written Tax Compliance Procedures <br /> The IRS Form 8038-G asks specific questions about whether written procedures exist with regard to compliance with the federal tax requirements for tax-exempt obligations. <br /> Please answer the following questions to help us complete the form Correctty prior to your signature.Please nnte that your answers to these questions xrill not impact the terms <br /> or canditions of the subject fransaction: <br /> t. Has the Lessee eslablished written procedures designed to monitor compliance with federal tax restrictions for the term of the lease?Among other matters,the written <br /> procedures should identify a particular individual within Lessee's organization to monitor compliance with the federal tax requirements related to use of the financed <br /> assets and descnbe actions to be taken in the event failure to comply with federal tax resVlctions is contemplated or discovered. <br /> YES ❑ QHO IA1 If YES,please attach/provide a copy. <br /> `�-.,.,� <br /> Answer the following question only i( proceeds ot the current tinancing will be tunded to an ESCROW Account. <br /> The IRS Form 8038-G asks spec'rfic questions about written procedures to monitor the yield on the investment of gross proceeds of ta�c-exempt obligations and,as necessary, <br /> make payments of arbitrage rebate earned to the United States. <br /> 2. Has the Lessee established written procedures to monitor the yield on the investment of proceeds of the Lease on deposit in an escrow account or similar fund prior to <br /> being spent and to ensure that any positive arbitrage rebate earned is paid to the United States? � <br /> (��Q YES ❑ NO ❑ If YES,please attach/provide a copy. ��,, <br /> t1� 1 a <br /> LL <br /> lf you have/urlher questions,please consult your regular bond or legal counse/. o <br /> �2016 NI Rights Reserved.P�imed m the 0.S.A.08PFDCC085vB t/l6 <br />