5100-142 Sponsor Request for FAA Acknowledgment for Cold Weather

U.S. Department
of Transportation

Federal Aviation
Administration

FAA Form 5100-142, Sponsor Request for FAA Acknowledgment for Cold Weather Early Start

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.

Sponsor Request for FAA Acknowledgement for
Cold Weather Early Start

Sponsor:      

Airport Name:      

Airport City, State:      

Project Title:      

49 USC §47110(b)(2)(D) provides for limited circumstances that allows the Federal Aviation Administration (FAA) to participate in construction costs that a Sponsor incurs prior to grant execution. The information in this form is necessary for FAA consideration of a sponsor’s request for early project start due to shortened construction season availability resulting from regional cold weather climate (FAA Order 5100.38D, Table 3-60). A sponsor may use a consultant or other representative to prepare this form. However, this form may only be signed by a duly authorized official of the airport sponsor. The Sponsor may not delegate either the signature acceptance or the certification acceptance to a consultant or contractor.

Project Information

If this project is part of a phased project, all required information (including the project total) applies to only the current phase being requested.

1. Project Description. Provide clear and concise description of project. (For example, mill and overlay 66,000 square yards of asphalt runway surface, including the intersection with Runway 9/27 and three adjoining taxiways (Alpha, Kilo and Sierra)).      

2. Total Project Cost. Provide the total amount, including all funding sources. $      

3. Proposed Funding Plan. Identify all amounts including all categories of Airport Improvement Program (AIP) funding requested as well as Passenger Facility Charges (PFCs), state funding, local funds, etc.      

4. Alternative Funding Plan. Provide the alternative funding source if AIP discretionary funds are not awarded. If future year AIP funding is the source of alternative funding, provide what the source of interim funding is until entitlement funds are available. Only future year passenger, cargo or non-primary entitlements are allowable sources of AIP funding.      

5. Date of Original AIP Funding Request. Provide the date of sponsor's capital improvement plan, or other document, containing the sponsor's original discretionary request to the FAA for this project.      

6. Date Bids Were (or Will be) Received. Bid Tabulation and Recommendation to Award must be attached if the project has been bid. If the project will be bid after this request for FAA Acknowledgement is being submitted, the bid tabulations and the recommendation for award must be submitted to the FAA prior to Notice to Proceed is issued.      

Construction Information

For phased projects, provide information for only the current phase being requested

1. Estimated Notice to Proceed (NTP) Date.      

2. Latest NTP Date. Provide the latest date construction can begin to avoid climatic conditions impact to construction schedule].      

3. Estimated Completion Date.      

4. Impacted Construction Activities. Describe specific construction activities that would be impacted or interrupted by cold-weather construction, including the nature of the impacts. Include a clear comparison of the proposed construction with and without early start, and a month-by-month summary of project impacts.      

5. Estimated Cost Impacts. Describe specific construction cost impacts if project is not started or completed according to the desired schedule. Include only physical construction cost impacts, excluding impacts related to construction administration.      

6. Other Impacts. Describe any other impacts that may result from schedule delays due to cold-weather climatic conditions      

7. Cold Weather Calculations. For each month of the calendar year, provide the average high and low air temperature at the airport (in degrees Fahrenheit).      

8. Public Data Source. Identify the publicly-published source for the above weather data, including a URL for online resources.      

Required Sponsor Certifications

Sponsor’s authorized official must initial each certification statement:

The sponsor understands that there is no guarantee of federal funding and no commitment on the part of the FAA to provide a future grant agreement for the above project. The sponsor has an alternate funding source to complete the project should federal funding not be available.

The sponsor understands that the FAA can only consider a grant containing discretionary funding in the same fiscal year as construction has started and the cost is incurred on the project.

The sponsor’s written request includes all necessary information required by the FAA to process the grant application.

The sponsor acknowledges their decision to move forward with the project, even with FAA acknowledgement, does not raise the priority of the project, nor increase the likelihood of receiving federal funding.

The sponsor will complete the project in accordance with all applicable FAA standards regardless of whether AIP discretionary funding is provided.

Official Sponsor Request

FAA acknowledgement does not in any manner signal intent of the FAA to award AIP Discretionary funds at a particular level or time. FAA action on this request only represents acknowledgement that the sponsor has taken the necessary steps, submitted the required documentation and accepted all of the risks should the sponsor choose to issue NTP prior to receiving a grant.

I hereby request FAA acknowledgement to issue Notice to Proceed prior to grant award.

Sponsor’s Certification

As a duly authorized official with the airport sponsor, I understand and accept all legal and financial risks (on behalf of the sponsor) associated with this request.

Executed on this       day      ,      .

Name of Sponsor:      

Name of Sponsor’s Authorized Official:      

Title of Sponsor’s Authorized Official:      

Signature of Sponsor’s Authorized Official: ___________________________________

I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and willfully providing false information to the federal government is a violation of 18 USC § 1001 (False Statements) and could subject me to fines, imprisonment, or both.

FAA Use Only Below This Line

Date Request Received: ___________

Date Due to Sponsor (30 calendar days after receipt): ___________

ADO/RO Staff Recommendation

• Issue FAA acknowledgement

• Do not issue FAA acknowledgement for reasons checked below

• Form and/or supporting documentation incomplete

• Grant application not received

• Construction not impacted by climatic (cold-weather) conditions

• No pending AIP Discretionary funding request

• Insufficient alternative funding plan

• Other issues involving project eligibility or justification

• Other issues involving construction procurement

• Other (describe):

Reviewed by ADO Manager (before forwarding to Regional Office):

ADO Manager’s Name:

ADO Manager’s Signature:

Date of Signature:

Date Forwarded to Regional Office:

Reviewed by Regional Airports Division Manager (before forwarding to APP-500):

Regional Airport Division Manager’s Name:

Regional Airport Division Manager’s Signature:

Date of Signature:

Date Forwarded to APP-500:

Reviewed by APP-500:

APP-500’s Name:

APP-500’s Signature:

Date of Signature:

APP-500 Determination:

ADO Manager or Regional Airports Division Manager Notification to Sponsor:

Name of Notifying FAA Official :

Title of Notifying FAA Official:

Date: