Form 5100-100 Application for Federal Assistance (Construction Program

Paperwork Reduction Act Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a
collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for
this information collection is 2120-0569. Public reporting for this collection of information is estimated to be approximately 28 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses are required to retain a benefit under 49 CFR 18.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: Federal Aviation Administration,
ARP-10, 800 Independence Ave SW, Washington DC, 20591.
DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

OMB NO. 2120-0569
1/31/2013

PART II

PROJECT APPROVAL INFORMATION

SECTION A

Item 1.
Does this assistance request require State,
local, regional, or other priority rating?

Name of Governing Body
Priority
Yes

No

Item 2.
Does this assistance request require State, local
advisory, educational or health clearances?

Name of Agency or Board
(Attach Documentation)
Yes

No

Item 3.
Does this assistance request require clearinghouse
review in accordance with OMB Circular A-95?
Yes

(Attach Comments)

No

Item 4.
Does this assistance request require State,
local, regional, or other planning approval?

Name of Approving Agency

Yes

No

/

/

Check One:

Item 5.
Is the proposed project covered by an approved
comprehensive plan?
Yes

No

Item 6.
Will the assistance requested serve a
Federal installation?

State
Local
Regional

Location of plan
Name of Federal Installation
Federal Population benefiting from Project

Yes

No

Item 7.
Will the assistance requested be on Federal land
or installation?

Name of Federal Installation
Location of Federal Land
Percent of Project
Yes

No

Item 8.
Will the assistance requested have an impact
or effect on the environment?

See instructions for additional information to be
provided.
Yes

No

Item 9.
Will the assistance requested cause the displacement
of individuals, families, businesses, or farms?
Yes

No

Item 10.
Is there other related Federal assistance on this
project previous, pending, or anticipated?

Number of:
Individuals
Families
Businesses
Farms
See instructions for additional information to be provided.

Yes
FAA Form 5100-100 (6-73) SUPERSEDES FAA FORM 5100-100 (9-03)

Date

No
Page 2

INSTRUCTIONS

PART II

SECTION A

Negative answers will not require an explanation unless the Federal agency requests more information at a later date. Provide
supplementary data for all “Yes” answers in the space provided in accordance with the following instructions.
Item 1. – Provide the name of the governing body
establishing the priority system and the priority rating
assigned to this project.
Item 2. – Provide the name of the agency or board which
issued the clearance and attach the documentation of
status or approval.
Item 3. – Attach the clearinghouse comments for the
application in accordance with the instructions contained
in Office of Management and Budget Circular No. A-95. If
comments were submitted previously with a
preapplication, do not submit them again but any
additional comments received from the clearinghouse
should be submitted with this application.

Item 6. – Show the Federal population residing or working
on the federal installation who will benefit from this project.
Item 7. – Show the percentage of the project work that will
be conducted on federally owned or leased land. Give the
name of the Federal installation and its location.
Item 8. – Briefly describe the possible beneficial and/or
harmful impact on the environment because of the
proposed project. If an adverse environmental impact is
anticipated, explain what action will be taken to minimize
the impact. Federal agencies will provide separate
instructions if additional data is needed.

Item 4. – Furnish the name of the approving agency and
the approval date.

Item 9. – State the number of individuals, families,
businesses, or farms this project will displace. Federal
agencies will provide separate instructions if additional
data is needed.

Item 5. – Show whether the approved comprehensive plan
is State, local or regional, or if none of these, explain the
scope of the plan. Give the location where the approved
plan is available for examination and state whether this
project is in conformance with the plan.

Item 10. – Show the Federal Domestic Assistance Catalog
number, the program name, the type of assistance, the
status and amount of each project where there is related
previous, pending, or anticipated assistance. Use
additional sheets, if needed.

DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

OMB NO. 2120-0569

PART II – SECTION C
The Sponsor hereby represents and certifies as follows:
1. Compatible Land Use. – The Sponsor has taken the following actions to assure compatible usage of land adjacent to or
in the vicinity of the airport:

2. Defaults. – The Sponsor is not in default on any obligation to the United States or any agency of the United States
Government relative to the development, operation, or maintenance of any airport, except as stated herewith:

3. Possible Disabilities. – There are no facts or circumstances (including the existence of effective or proposed leases, use
agreements or other legal instruments affecting use of the Airport or the existence of pending litigation or other legal
proceedings) which in reasonable probability might make it impossible for the Sponsor to carry out and complete the Project
or carry out the provisions of Part V of this Application, either by limiting its legal or financial ability or otherwise, except as
follows:

4. Consistency with Local Plans. – The project is reasonably consistent with plans (existing at the time of submission of this
application) of public agencies that are authorized by the State in which the project is located to plan for the development of
the area surrounding the airport.
5. Consideration of Local Interest. – It has given fair consideration to the interest of communities in or near where the
project may be located.
6. Consultation with Users. In making a decision to undertake any airport development project under Title 49, United
States Code, it has undertaken reasonable consultations with affected parties using the airport at which project is proposed.
7. Public Hearings. – In projects involving the location of an airport, an airport runway or a major runway extension, it has
afforded the opportunity for public hearings for the purpose of considering the economic, social, and environmental effects
of the airport or runway location and its consistency with goals and objectives of such planning as has been carried out by
the community and it shall, when requested by the Secretary, submit a copy of the transcript of such hearings to the
Secretary. Further, for such projects, it has on its management board either voting representation from the communities
where the project is located or has advised the communities that they have the right to petition the Secretary concerning a
proposed project.
8. Air and Water Quality Standards. – In projects involving airport location, a major runway extension, or runway location it
will provide for the Governor of the state in which the project is located to certify in writing to the Secretary that the project
will be located, designed, constructed, and operated so as to comply with applicable and air and water quality standards. In
any case where such standards have not been approved and where applicable air and water quality standards have been
promulgated by the Administrator of the Environmental Protection Agency, certification shall be obtained from such
Administrator. Notice of certification or refusal to certify shall be provided within sixty days after the project application has
been received by the Secretary.

FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73)

Page 3a

DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

OMB NO. 2120-0569

PART II – SECTION C (CONTINUED)
9. Exclusive Rights. – There is no grant of an exclusive right for the conduct of any aeronautical activity at any airport
owned or controlled by the Sponsor except as follows:

10. Land. – (a) The sponsor holds the following property interest in the following areas of land* which are to be developed
or used as part of or in connection with the Airport subject to the following exceptions, encumbrances, and adverse
interests, all of which areas are identified on the aforementioned property map designated as Exhibit “A”:

The Sponsor further certifies that the above is based on a title examination by a qualified attorney or title company and that
such attorney or title company has determined that the Sponsor holds the above property interests.
(b)
The Sponsor will acquire within a reasonable time, but in any event prior to the start of any construction
work under the Project, the following property interest in the following areas of land* on which such construction work is to
be performed, all of which areas are identified on the aforementioned property map designated as Exhibit “A”:

(c)
The Sponsor will acquire within a reasonable time, and if feasible prior to the completion of all
construction work under the Project, the following property interest in the following areas of land* which are to be developed
or used as part of or in connection with the Airport as it will be upon completion of the Project, all of which areas are
identified on the aforementioned property map designated as Exhibit “A”:

*State character of property interest in each area and list and identify for each all exceptions, encumbrances, and adverse
interests of every kind and nature, including liens, easements, leases, etc. The separate areas of land need only be identified
here by the area numbers shown on the property map.

FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100(4-76)

Page 3b

DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

OMB NO. 2120-0569

PART III – BUDGET INFORMATION – CONSTRUCTION
SECTION A – GENERAL
1.

Federal Domestic Assistance Catalog No.

2.

Functional or Other Breakout

SECTION B - CALCULATION OF FEDERAL GRANT
Use only for revisions

COST CLASSIFICATION
1.

Administration expense

2.

Preliminary expense

3.

Land, structures, right-of-way

4.

Architectural engineering basic fees

5.

Other architectural engineering fees

6.

Project inspection fees

7.

Land development

8.

Relocation expenses

9.

Relocation payments to individuals and businesses

10.

Demolition and removal

11.

Construction and project improvement

12.

Equipment

13.

Miscellaneous

14.

Total (Lines 1 through 13)

15.

Estimated Income (if applicable)

16.

Net Project Amount (Line 14 minus 15)

17.

Less: Ineligible Exclusions

18.

Add: Contingencies

19.

Total Project Amt. (Excluding Rehabilitation Grants)

20.

Federal Share requested of Line 19

21.

Add Rehabilitation Grants Requested (100 percent)

22.

Total Federal grant requested (Lines 20 & 21)

23.

Grantee share

24.

Other shares

25.

Total project (Lines 22, 23, & 24)

FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73)

Latest Approved
amount

$

Adjustment + or
(-)

$

$

Total Amount
Required

$

$

$
Page 4

INSTRUCTIONS

PART III

SECTION A. GENERAL

1. Show the Federal Domestic Assistance Catalog Number
from which the assistance is requested. When more than
one program or Catalog Number is involved and the amount
cannot be distributed to the Federal grant program or catalog
number on an over-all percentage basis, prepare a separate
set of Part III forms for each program or Catalog Number.

However, show the total amounts for all programs in
Section B of the basic application form.
2. Show the functional or other categorical breakouts, if
required by the Federal grantor agency. Prepare a separate
set of Part III forms for each category.

SECTION B. CALCULATION OF FEDERAL GRANT
When applying for a new grant, use the Total Amount Column only. When requesting revisions of previously awarded
amounts, use all columns.
Line 1 - Enter amounts needed for administration expenses
including such items as travel, legal fees, rental of vehicles
and any other expense items expected to be incurred to
administer the grant. Include the amount of interest expense
when authorized by program legislation and also show this
amount under Section E Remarks.
Line 2 - Enter amounts pertaining to the work of locating and
designing, making surveys and maps, sinking test holes, and
all other work required prior to actual construction.
Line 3 - Enter amounts directly associated with the
acquisition of land, existing structures, and related right-of
way.
Line 4 - Enter basic fees for architectural engineering
services.
Line 5 - Enter amounts for other architectural engineering
services, such as surveys, tests, and borings.
Line 6 - Enter fees for inspection and audit of construction
and related programs.
Line 7 - Enter amounts associated with the development of
land where the primary purpose of the grant is land
improvement. Site work normally associated with major
construction should be excluded from this category and
shown on line 11.
Line 8 - Enter the dollar amounts needed to provide
relocation advisory assistance, and the net amounts for
replacement (last resort) housing. Do not include relocation
administration expenses on this Line; include them on Line 1.
Line 9 - Enter the estimated amount of relocation payments
to be made to displaced persons, business concerns, and
non-profit organizations for moving expenses and
replacement housing.
Line 10 - Enter the gross salaries and wages of employees
of the grantee who will be directly engaged in performing
demolition or removal of structures from developed land.
This line should show also the cost of demolition or
removal of improvements on developed land under a third
party contract. Reduce the costs on this line by the amount
of expected proceeds from the sale of salvage, if so
instructed by the Federal grantor agency. Otherwise, show
the proceeds on Line 15.
Line 11 - Enter amounts for the actual construction of,
addition to, or restoration of a facility. Also, include in this
category the amounts of project improvements such as
sewers, streets, landscaping, and lighting.

Line 12 - Enter amounts for equipment both fixed and
movable exclusive of equipment used in construction. For
example, include amounts for permanently attached lab
oratory tables, built-in audio visual systems, movable desks,
chairs, and laboratory equipment.
Line 13 - Enter amounts for items not specifically mentioned
above.
Line 14 - Enter the sum of Lines 1-13.
Line 15 - Enter the estimated amount of program income that
will be earned during the grant period and applied to the
program.
Line 16 - Enter the difference between the amount on Line
14 and the estimated income shown on Line 15.
Line 17 - Enter the amounts for those items which are a part
of the project but not subject to Federal participation (See
Section C, Line 26g, Column (1)).
Line 18 - Enter the estimated amount for contingencies.
Compute this amount as follows. Subtract from the net
project amount shown on Line 16 the ineligible project
exclusions shown on Line 17 and the amount which is
excluded from the contingency provisions shown in Section
C, Line 26g, Column (2). Multiply the computed amount by
the percentage factor allowed by the grantor agency in
accordance with the Federal program guidance. For those
grants which provide for a fixed dollar allowance in lieu of a
percentage allowance, enter the dollar amount of this
allowance.
Line 19 - Show the total amount of Lines 16, 17, and 18.
(This is the amount to which the matching share ratio pre
scribed in program legislation is applied.)
Line 20 - Show the amount of Federal funds requested
exclusive of funds for rehabilitation purposes.
Line 21 - Enter the estimated amounts needed for
rehabilitation expense if rehabilitation grants to individuals
are made for which grantees are reimbursed 100 percent by
the Federal grantor agency in accordance with program
legislation. If the grantee shares in part of this expense,
show the total amount on Line 13 instead of on Line 21 and
explain in Section E.
Line 22 - Show the total amount of the Federal grant re
quested.
Line 23 - Show the amount from Section D, Line 27h.
Line 24 - Show the amount from Section D, Line 28c.
Line 25 - Self-explanatory.

DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

OMB NO. 2120-0569

SECTION C - EXCLUSIONS
Ineligible for
Participation
(1)

26. Classification
a.

Excluded from
Contingency Provision
(2)

$

$

$

$

b.
c.
d.
e.
f.
g.

Totals

SECTION D - PROPOSED METHOD OF FINANCING NON-FEDERAL SHARE
$

27. Grantee Share
a.

Securities

b.

Mortgages

c.

Appropriations (By Applicant)

d.

Bonds

e.

Tax Levies

f.

Non Cash

g.

Other (Explain)

h.

Total – Grantee Share

28. Other Shares
a.

State

b.

Other

c.

Total Other Shares

$

29. TOTAL

SECTION E - REMARKS

PART IV - PROGRAM NARRATIVE (ATTACH – SEE INSTRUCTIONS)
FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73)

PAGE 5

INSTRUCTIONS
PART III
SECTION C. EXCLUSIONS
Line 26 a-g - Identify and list those costs in Column (1)
which are part of the project cost but are not subject to
Federal participation because of program legislation or
Federal grantor agency instructions. The total amount on
Line g should agree with the amount shown on Line 17 of

Section B. Show in Column (2) those project costs that are
subject to Federal participation but are not eligible for
inclusion in the amount used to compute contingency
amounts as provided in the Federal grantor agency
instructions.

SECTION D. PROPOSED METHOD OF FINANCING NON-FEDERAL SHARE
Line 27 a-g - Show the source of the grantee’s share. If
cash is not immediately available, specify the actions
completed to date and those actions remaining to make cash
available under Section E Remarks. Indicate also the period
of time that will be required after execution of the grant
agreement to obtain the funds. If there is a noncash
contribution, explain what this contribution will consist of.

state agency. If there is a noncash contribution, explain what
the contribution will consist of under Section E Re-marks.
Line 28b - Show the amount that will be contributed from
other sources. If there is a noncash contribution, explain
what the contribution will consist of under Section E Remarks.

Line 27h - Show the total of Lines 27 a-g. This amount must
equal the amount shown in Section B, Line 23.

Line 28c - Show the total of Lines 28a and 28b. This amount
must be the same as the amount shown in Section B,

Line 24.

Line 28a - Show the amount that will be contributed by a

State or state agency, only if the applicant is not a State or

Line 29 - Enter the totals of Line 27h and 28c.

SECTION E. OTHER REMARKS
Make any remarks pertinent to the project and provide any
other information required by these instructions or the grantor
agency. Attach additional sheets, if necessary.

PART IV

PROGRAM NARRATIVE

(Suggested Format)
DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

OMB NO. 2120-0569

PROJECT:
AIRPORT:
1. Objective:

2. Benefits Anticipated:

3. Approach: (See approved Scope of Work in final Application)

4. Geographic Location:

5. If Applicable, Provide Additional Information:

6: Sponsor’s Representative: (incl. address & tel. no.)

FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73)

PAGE 6

INSTRUCTIONS

PART IV

PROGRAM NARRATIVE

Prepare the program narrative statement in accordance with the following instructions for all new grant programs. Requests
for supplemental assistance should be responsive to Item 5b only. Requests for continuation or refunding or other changes of
an approved project should be responsive to Item 5c only.
1. OBJECTIVES AND NEED FOR THIS ASSISTANCE.
Pinpoint any relevant physical, economic, social, financial,
institutional, or other problems requiring a solution.
Demonstrate the need for assistance and state the principal and
subordinate objectives of the project. Supporting documentation
or other testimonies from concerned interests other than the
applicant may be used. Any relevant data based on planning
studies should be included or footnoted.
2. RESULTS OR BENEFITS EXPECTED.
Identify results and benefits to be derived. For example, include a
description of who will occupy the facility and show how the facility
will be used. For land acquisition or development projects, explain
how the project will benefit the public.
3. APPROACH
a. Outline a plan of action pertaining to the scope and detail of how
the proposed work will be accomplished for each grant program.
Cite factors which might accelerate or decelerate the work, and your
reason for taking this approach as opposed to others. Describe any
unusual features of the project such as design or technological
innovations, reductions in cost or time, or extraordinary social and
community involvements.
b. Provide each grant program monthly or quarterly quantitative
projections of the accomplishments to be achieved, if possible.
When accomplishments cannot be quantified, list the activities in
chronological order to show the schedule of accomplishments and
their target dates.
c. Identify the kinds of data to be collected and maintained, and
discuss the criteria to be used to evaluate the results and success of
the project. Explain the methodology that will be used to determine
if the needs identified and discussed are being met and if the results
and benefits identified in Item 2 are being achieved.

d. List each organization, cooperator, consultant, or other key
individuals who will work on the project along with a short
description of the nature of their effort or contribution.
4. GEOGRAPHIC LOCATION.
Give a precise location of the project and area to be served by the
proposed project. Maps or other graphic aids may be attached.
5. IF APPLICABLE, PROVIDE THE FOLLOWING
INFORMATION:
a. Describe the relationship between this project and other work
planned, anticipated, or underway under the Federal Assistance
listed under Part II, Section A, Item 10.
b. Explain the reason for all requests for supplemental assistance
and justify the need for additional funding.
c. Discuss accomplishments to date and list in chronological order
a schedule of accomplishments, progress, or milestones anticipated
with the new funding re-quest. If there have been significant
changes in the project objectives, location, approach or time delays,
explain and justify. For other requests for changes or amendments,
explain the reason for the change(s). If the scope or objectives
have changed or an extension of time is necessary, explain the
circumstances and justify. If the total budget has been exceeded or
if individual budget items have changed more than the prescribed
limits contained in Attachment K, Office of Management and Budget
Circular No. A-102, explain and justify the change and its effect on
the project.