5100-126 Financial Governmental Payment Report

FORM APPROVED
OMB NO. 2120-0569 1/31/2013

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
Title

Date
Telephone No.

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 3 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: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

FAA Form 5100-126

4/01
Previous editions are obsolete.