5100-136 Buy American Content Percentage Calculation Worksheet

U.S. Department
of Transportation

Federal Aviation
Administration

FAA Form 5100-136, Buy American Content Percentage Calculation Worksheet

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 8 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 to this collection of information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Federal Aviation Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110.

Buy American Content Percentage Calculation Worksheet

Company Name:       Date:      

Address:       Point of Contact:      

Telephone:       Fax:       Email:      

Product Structure: Multi-Level Bill of Materials (through level 2 only)

Item Description:       Total Material Cost:      

Address of Final Assembly Location:       US Content (%):      

FAA Item Number (if applicable):       Other (%):      

The undersigned certifies that this information is true and accurate to the best of their knowledge.¹

Signature: ___________________________

Name:      

Level (0, 1, 2)	Part Number	Description	Quantity Per Unit	Unit of Measure	Price/Unit of Measure	US Origin Price/Unit of Measure2	US Origin* Cost/Each	Other Price/Unit of Measure	Other Cost/Each
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     

1 A false certification represents a violation of 18 U.S.C § 1001 and 49 U.S.C § 47126. Signatory has the burden of proof to establish compliance.

2 Items listed in Federal Acquisition Regulation Part 25.104 may be counted as US Origin, however should include note stating that item is exempt in 25.104.