1. Name of entity ___________________________________________________________________________

2. Identifying information on reimbursement contract:

    Name ___________________________________________________________________________________

    Series __________________________________________________ Issue Date ______________________

    Amount of Original Issue ___________________________________________________________________

    Principal and Interest Payment Dates: Principal ______________ Interest _______________

3. IRS Form 8038G or 803GC executed? Yes __________________ No ___________________

4. Net present value savings ___________________________________________________________________

5. Date request for prepayment approval received __________________________________________________

6. Forwarded to State Debt Analyst II (date) ______________________________________________________

7. Cost of prepayment:

    a. Principal $ ____________________

    b. Interest $ ____________________

    c. Redemption premium, if any $ ____________________

    d. Less Reserves $ ____________________

    e. Total amount due for prepayment $ ____________________

9. Verification received from Chief Financial Officer _______________________________________________

10. Prepayment received on (date) ________________________________________

11. Arbitrage yield certificate attached: Yes _________ No _________

12. Reimbursement Prepayment Receipt Form completed on __________________________________________

13. Funds deposited into Capital Outlay Escrow Account on __________________________________________

14. Yield restricted to rate of ___________________________________________________________________