ATTACHMENT IV
| Agency Name:__________________ | Contact Person:____________________ | Phone:____________ |
| Agency/Program No. | Program Description |
Justification for Exemption from |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| __ __ __ __ __ __ | ________________________________ | _________________ |
| ___________________ | ___________________________ | |
| Date | Approved by Agency Head |
Instructions: This form should be used to list those programs that do not need to utilize the Tax-Exempt Bond Proceeds Fund. An example would be any program whose payments derive from taxable bonds. If there is any doubt about the eligibility of a project for exemption from the Tax-Exempt Bond Proceeds Fund, it should be included in the TEBPF program. Please submit the original of this form to OPM with copies to the State Treasurer and the State Comptroller. NOTE: An Agency should use only one agency number.
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