5100-126 Financial Governmental Payment Report

FORM APPROVED
OMB NO. 2120-0569 11/30/2007

AC 150/5100-19B (Appendix 2)

FINANCIAL GOVERNMENTAL PAYMENT REPORT
Please complete this form using a san serif (Helvetica, Arial, etc.), 7-point font.
Airport Name

Location ID

Fiscal Year End

Payments to other government units -- Please complete a separate form for each unit of government (City, County, State, Federal).
Name of government entity:
Type of Payment
Law enforcement
Firefighting
Legal services
Engineering
Mayor and City Council
General cost of government
Central services
Payments in lieu of tax

Amount
$
$
$
$
$
$
$
$

-

Type of Payment
Impact fees
Utilities
Fleet services
Promotion and marketing
Repayment of contributions
Repayment of loans
Lobbying fees
Ground access projects

Amount
$
$
$
$
$
$
$
$

-

Type of Payment
Community services
Grandfathered payments
Land and facility rental
Parking and sales tax
Aviation fuel tax
Other - Please attach a schedule.

Amount

Total

$
$
$
$
$
$

-

$

-

Do not include payments of less than $1,000 or payments for payroll tax, workers compensation, employee benefits, FICA, or contributions to employee retirement accounts
Property and (or) services provided to other units of governments -- Please complete a separate form for each unit of government. Do not list FAA navigational facilities.
Name of government entity:
Property and (or) Service Provided
Department
(Including services provided by AP employees)
Use*
Type**
Fair Market Value
Value of In-Kind Services***
Cash Compensation

Use* - Please enter "A" for aeronautical or "N" for nonaeronautical.
Type** - Please enter "FMV" for fair market value, "L" for less than fair market value, or "N" for nominal.
Value of In-Kind Services*** - When the tenant pays a portion of the lease by providing services to the airport, please enter the value of the services provided and attach a note describing the service.

In compliance with 47107(a) of Title 49 United States Code and section 111(b)

I certify that the information on this form is true and accurate to the best of my knowledge and belief.

of the Federal Aviation Administration Authorization Act of 1994, please complete
this form to help the public understand airport finances and the
use of airport-generated revenue.

Signature
Printed Name

Date

Title

Telephone No.

Paperwork Reduction Act Statement: The information collected on this form facilitates the submission of financial payment data. Financial Governmental Payment Form, section 471207(a)(19), requires airport owners and operators to submit to the Secretary of
Transportation and make available to the public an annual report listing all amounts paid by the airport to other units of government and the purpose of payment. Airport Owners or operators must also make available a listing of all services and property provided to
other units of government and the amount of compensation received for provision of each such service and property. The burden for each response is estimated to be 3 hours. Responses are required to obtain a benefit. No assurance of confidentiality is given.
Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with this collection is 2120-0569.
Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20 .

FAA Form 5100-126

4/01
Previous editions are obsolete.