1.Name of prepaying entity ___________________________________________________________________

2. Identifying information on reimbursement contract to be prepaid:

    Name ___________________________________________________________________________________

    Series ___________________________________ Issue Date __________________________________

    Amount of Original Issue ____________________________________________________________________

    Principal and Interest Payment Dates: Principal ________________ Interest ________________

3. Check No. ________________________________________________________________________________

4. Date _____________________________________________________________________________________

5. Amount received ___________________________________________________________________________

6. Date received ______________________________________________________________________________

7. Deposited into: (Account Name) ____________________________________________________________

8. Yield restricted or yield reduction payments owed in accordance with the following rate:

    a. Rate of arbitrage yield for prepaying entity ____________________________________________________

    b. Rate of arbitrage yield for state bond issue _____________________________________________________

9. Source of Funding

    a. Local Bond Issue ? ________________________________________________________________________