Okaloosa County BOCC — January 7, 2014 — grader-lease-Contracts — reading text

provisions of U.S. law. Financial Institution Name Branch Address City State Zip Routing Number Account Number Type of Account [7 checking (savings This authority is to remain in full force and effect until Kansas State Bank has received written notification from any authorized signer of the account of its termination in such time and manner as to afford Kansas State Bank a reasonable opportunity to act on it. Obligor Name on Contract Okaloosa County Board of Commissioners Signature Printed Name and Title Tax ID Number Date 59-6000765 PLEASE ATTACH COPY OF A VOIDED CHECK TO THIS FORM! USA Patriot Act USA Patriot Act requires identity verification for all new accounts. This means that we may require information from you to allow us to make a proper identification. INVOICE BILL TO: Okaloosa County Board of Commissioners INVOICE DATE: November 22, 2013 Attn: Accounts Payable CONTRACT NUMBER: 3345088 302 N. Wilson Street, Suite 203 PAYMENT AMOUNT: $5,325.53 Crestview, Florida 32536 PAYMENT DUE DATE: At Closing DESCRIPTION AMOUNT Contract Payment $5,325.53 Lease with Option to Purchase Agreement Dated as of August 19, 2013 for Four (4) Volvo G930B Motor Graders, SN: 576117, 576118, 576119, 576120 Additional interest will be assessed on any payment received after the due date. $5,325.53 TOTAL DUE Please remit paymentto: Kansas State Bank Government Finance Dept. P.O. Box 69 Manhattan, KS 66505-0069 For inquiries: (877) 587-4054 INVOICE BILL TO: Okaloosa County Board of Commissioners INVOICE DATE: November 22, 2013 Attn: Accounts Payable CONTRACT NUMBER: 3345088 302 N. Wilson Street, Suite 203 PAYMENT AMOUNT: $5,325.53 Crestview, Florida 32536 PAYMENT DUE DATE: February 15, 2014 DESCRIPTION AMOUNT Contract Payment $5,325.53 Lease with Option to Purchase Agreement Dated as of August 19, 2013 for Four (4) Volvo G930B Motor Graders, SN: 576117, 576118, 576119, 576120 Additional interest will be assessed on any payment received after the due date. $5,325.53 Please remit paymentto: Kansas State Bank Government Finance Dept. P.O. Box 69 Manhattan, KS 66505-0069 For inquiries: (877) 587-4054 8038 REVIEW FORM The 8038 form attached hereto is an important part of the documentation package and must be properly filled out and submitted to the Department of the Treasury in order for you to receive the lower tax-exempt rate. Unless you instruct us otherwise, we have engaged a Paid Preparer to assist in the filling out of this form. The Paid Preparer has filled out the relevant portions of this form based on the current understanding of what is required by the Department of the Treasury. The responses on this 8038 form are based on the dates and amounts which you have requested (structure of the transaction) and which are on the Payment Schedule. 1. Please review our responses for accuracy. !f anything is inaccurate, please contact our office so that we can make proper revisions. 2. if the information provided to you on this form is accurate, please sign where indicated and return with the document package. 3. ‘if there are any changes to the structure of the transaction that occur prior to funding which require a change to the 8038 form, we will make such changes and provide notification to you. 4. Wewill return to you a copy of the 8038 form that was mailed to the Department of the Treasury. Important Note: The IRS is now requesting information regarding tax-exempt issuers’ and borrowers’ written policies and procedures designed to monitor post- issuance compliance with the federal tax rules applicable to tax-exempt obligations (boxes 43 and 44). Do not check items 43 and 44 on the 8038 form unless you have established written procedures in accordance with the instructions referenced directly below. If you choose to “check” items 43 and/or 44, please be prepared to provide copies of such written procedures to the Paid Preparer or any representatives of the IRS upon request. Written procedures should contain certain key characteristics, including making provisions for: © Due diligence review at regular intervals; » Identifying the official or employee responsible for review; * Training of the responsible official/employee; « Retention of adequate records to substantiate compliance (e.g., records relating to expenditure of proceeds); * Procedures reasonably expected to timely identify noncompliance; and * Procedures ensuring that the issuer will take steps to timely correct noncompliance. For additional guidance on this 8038 form, you can refer to the Documentation Instructions located on the following government website: http://www. irs.gov/app/picklist/list/formsinstructions.html, or contact your local IRS office. rom 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: /f the issue price is under $100,000, use Form 8038-GC. Reporting Authority if Amended Return, check here » [1] 1 Issuer's name 2 Issuers employer identification number (EIN) Okaloosa County Board of Commissioners 59-6000765 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) Reonysuite & Report number (For IRS Use Only) 302 N. Wilson Street, Suite 203 Ls | | 6 City, town, or post office, state, and ZIP code 7 ~~ Date of issue Crestview, Florida 32536 01/15/2014 8 Name ofissue , 9 CUSIP number Lease with Option to Purchase Agreement None 10a Name and title of officer or other employee of the issuer whom the IRS may cail for more information (seq 10b Telephone number of officer or other instructions) employee shown on 10a Type of issue (enter the issue price). See the instructions and attach schedule. 44 Education 2 2 ee Ed 12 Healthandhospital ....... ee ee 12 13. Transportation 2... 1 2 ee ee 1 14 Publicsafety 2.2 2]. eb‘ 18 Environment (including sewage bonds} | ee ee LS 16 Housing... 2... ee ee ee LB 17° «(Utilities 2. LAF 18 Other. Describe ® Four (4) Volvo G930B Motor Graders, SN: 576117, 576118, 576119, 576120 18 743,161 | 48 19 = ‘If obligations are TANs or RANs, check onlybox19a 2. 2 1... > O If obligations are BANs, check only box 19b . . . . woe >» O 20 ‘If obligations are in the form of a lease or installment sale, check box >» wi Description of Obligations. Complete for the entire issue for which this form is being filed. (a) Final maturity date (b) issue price (e) eae a eeemeyen an ane otesty {e) Yield 21 01/15/2017 $ 743,161.48 $ NIA 3.080 years 2.370 % Uses of Proceeds of Bond Issue (including underwriters’ discount) 22 Proceeds used for accrued interest... . . ee ee eee £22 23 _ Issue price of entire issue (enter amount from line 21, colurnn (b)) Se ee 23 24 Proceeds used for bond issuance costs (including underwriters’ discount) . . . . | 24 25 Proceeds used forcreditenhancement ............... -. . | 28 26 ~=Proceeds allocated to reasonably required reserve or or replacement fund 2.2... 26 27 ~—~ Proceeds used to currently refund priorissues 5. 2. . . £27 28 Proceeds used to advance refund prierissues 2 2 2... So ee . £28 29 =Total (add lines 24 through 28) © 6 ww woe ee ee ee 28 30 _Nonrefunding proceeds of the issue (subtract ine 29 from line 23 and enter amount here) wee 30 Description of Refunded Bonds. Complete this part only for refunding bonds. 34 Enter the remaining weighted average maturity of the bonds to be currentlyrefunded © 2. 2. 1 2 years 32 ~~ Enter the remaining weighted average maturity of the bonds tobe advance refunded .. 2... 2 1. 1. years 33 ~~ Enter the last date on which the refunded bonds willbe called (MM/DD/YYYY) . 2... 2... 34 Enter the date(s) the refunded bonds were issued » (MM/DD/YYYY) we 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 Pi Miscellaneous 35 Enter the amount of the state volume cap allocated to the issue under section 144(b)(5) 2 2 2 2 35 36a Enter the amount of gross proceeds invested or to be invested in a guaranteed investment contract (GIC) (see instructions) . 2... Coe ee be wee wee ee | 868 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 2 2. 2. 2 eee : soe eee toe .| 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 > Enter the EIN of the issuer of the master pool obligation >» 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 (Ill) (small issuer exception), checkbox. . 2... 2. OM 40 If the issuer has elected to pay a penalty in lieu of arbitrage rebate, checkbox... 2... 2... 7. eee ee ee eee > 6h 41a if the issuer has identified a hedge, check here » [] and enter the following information: Name of hedge provider » Type of hedge > d= Term of hedge » 42 ‘if the issuer has superintegrated the hedge, checkbox. . . . . . . . rrr » 43 if the issuer has established written procedures to ensure that all nonqualified b bonds of this i issue are remediated according to the requirements under the Code and Regulations (see instructions), check box 6 2. 2 > 44 If the issuer has established written procedures to monitor the requirements of section 148, check box >» O 45a if some portion of the proceeds was used to reimburse expenditures, check here » {J and enter the amount ofreimbursement. . 2 2. 2... b Enter the date the official intent was adopted > [onder penalties of perjury, | declare that | have examined this return and accompanying schedules and statements, and to the best of my knowledge Signature ind belief, they are true, correct, and complete, ! further declare that | consent to the IRS’s disclosure of the issuer's return information, as necessary to and process this retum, to the person that i have authorized above. Consent | p> > Signature of issuers authorized representative Date Type or print name and title PrintType preparers name Preparer's signature Date PTIN Paid dd: £, SFE eeserenpeeuen Cheek [J it Preparer H. Evan Howe Rowe ieee 1412212013 self-employed P01438994 Use Only Firm's Name» Baystone Financial LLC Firm's EIN > 48-1223987 Firm's Address » 5350 College Blvd., Overland Park, KS 66211 Phone ne. {800) 752-3562 Form 8038-G (Rev. 9-2011))