5100-139 LOI Application Financial Template

Airports Grants Program

Copy of FAA Form 5100-139 LOI Application Financial Template.xlsx

Airports Grants Program Financial Management

OMB: 2120-0569

Document [xlsx]
Download: xlsx | pdf

Overview

PRA Statement
Program-Level Data Entry
Alternative Disbursement Sched
Project-Level Data Entry
Summary Analytical Sheet


Sheet 1: PRA Statement


FAA Form 5100-139, Letter of Intent (LOI) Application Financial Template

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.

Sheet 2: Program-Level Data Entry

LOI Application Financial Template



















Order 5100.38C






















Sponsors requesting Letters of Intent (LOIs) are required to submit the information shown, in substantially the same format as this template. Sponsors are strongly encouraged to use this template, as it may help to expedite the review and approval process. Regardless, Sponsors should review the instructions contained in Chapter 6 of Order 5100.38Dcarefully, because those instructions contain specific parameters for what to include on certain key lines of this template.




























Airport Sponsor Information










































1 [insert airport name]



















2 [insert three-letter identifier]



















3 [insert city and state]



















4 [insert hub category - Large, Medium, Small or Nonhub]



















5 [insert airport owner/operator -- e.g., "City of East Rutherford"]



















6 [insert submission date]









































Capital Costs and Annual Cashflow Requirements - Proposed Action














































Totals as %
Prior Years FFY-2015 FFY-2016 FFY-2017 FFY-2018 FFY-2019 FFY-2020 FFY-2021 FFY-2022 FFY-2023 FFY-2024 FFY-2025 FFY-2026 FFY-2027 FFY-2028
7 Professional Services

$0 n/a















8 Land Acquisition

0 n/a















9 Runway [insert runway designation]
0 n/a















10 Runway [insert runway designation]
0 n/a















11 Runway [insert runway designation]
0 n/a















12 Runway [insert runway designation]
0 n/a















13 Other Airside

0 n/a















14 Terminal

0 n/a















15 Landside

0 n/a















16 Infrastructure

0 n/a
















Summary

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Cumulative Needs




$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















Capital Funding Sources - Proposed Action














































Totals as %
Prior Years FFY-2015 FFY-2016 FFY-2017 FFY-2018 FFY-2019 FFY-2020 FFY-2021 FFY-2022 FFY-2023 FFY-2024 FFY-2025 FFY-2026 FFY-2027 FFY-2028

Federal and State Grants



















17 Entitlements - Grants Awarded

$0 n/a















18 Entitlements - Future Grants

0 n/a















19 Discretionary - LOI Request

0 n/a















20 Discretionary - Other - Awarded

0 n/a















21 Discretionary - Other - Future Grants

0 n/a















22 Discretionary - Noise - Awarded

0 n/a















23 Discretionary - Noise - Future Grants

0 n/a















24 State Apportionment - Grants Awarded

0 n/a















25 State Apportionment - Future Grants

0 n/a















26 Other Federal (non-AIP) - Grants Awarded

0 n/a















27 Other Federal (non-AIP) - Future Grants

0 n/a















28 State - Grants Awarded

0 n/a















29 State - Future Grants

0 n/a
















Subtotal - Federal/State Grants

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Passenger Facility Charges



















30 PFCs - $3.00 Application Approved

$0 n/a















31 PFCs - $3.00 Application Submitted

0 n/a















32 PFCs - $3.00 Future Application(s)

0 n/a















33 PFCs - $4.50 Application Approved

0 n/a















34 PFCs - $4.50 Application Submitted

0 n/a















35 PFCs - $4.50 Future Application(s)

0 n/a















36 PFCs - Future Level
[assumed level] 0 n/a
















Subtotal - PFCs

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Debt



















37 Revenue Bonds - MII Approved

$0 n/a















38 Revenue Bonds - MII pending

0 n/a















39 General Obligation - Authority in Place

0 n/a















40 General Obligation - Authority Pending

0 n/a















41 Other Debt - Authority in Place

0 n/a















42 Other Debt - Authority Pending

0 n/a
















Subtotal - Debt

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















43 Airport Funds

$0 n/a















44 Tenant or Third-Party Funds

$0 n/a




















n/a
















Total - All Funding Sources

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Cumulative Sources




$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















Unmet Funding Needs


Totals

Prior Years 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028


























$0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

























Summary Funding Sources




















Discretionary - LOI Request $0



















Other AIP funds $0



















Other Federal funding $0



















State grants 0



















PFCs $0



















Bonds $0



















Other $0



















Total $0









































Funding Status




















Discretionary - LOI Request $0



















Grants awarded $0



















Approved PFCs $0



















Approved bonds $0



















Future grants $0



















Future PFCs $0



















Future bonds $0



















Other $0



















Total $0
















Capital Costs and Annual Cashflow Requirements - Other Capital Plans














































Totals as %
Prior Years FFY-2015 FFY-2016 FFY-2017 FFY-2018 FFY-2019 FFY-2020 FFY-2021 FFY-2022 FFY-2023 FFY-2024 FFY-2025 FFY-2026 FFY-2027 FFY-2028
45 Professional Services

$0 n/a















46 Land Acquisition

0 n/a















47 Runways

0 n/a















48 Other Airside

0 n/a















49 Terminal

0 n/a















50 Landside

0 n/a















51 Infrastructure

0 n/a
















Summary

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Cumulative Needs




$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















Capital Funding Sources - Other Capital Plans



n/a




















n/a



















Totals as %
Prior Years FFY-2015 FFY-2016 FFY-2017 FFY-2018 FFY-2019 FFY-2020 FFY-2021 FFY-2022 FFY-2023 FFY-2024 FFY-2025 FFY-2026 FFY-2027 FFY-2028

Federal and State Grants



















52 Entitlements - Grants Awarded

$0 n/a















53 Entitlements - Future Grants

0 n/a















54 Discretionary - LOI Request

0 n/a















55 Discretionary - Other - Awarded

0 n/a















56 Discretionary - Other - Future Grants

0 n/a















57 Discretionary - Noise - Awarded

0 n/a















58 Discretionary - Noise - Future Grants

0 n/a















59 State Apportionment - Grants Awarded

0 n/a















60 State Apportionment - Future Grants

0 n/a















61 Other Federal (non-AIP) - Grants Awarded

0 n/a















62 Other Federal (non-AIP) - Future Grants

0 n/a















63 State - Grants Awarded

0 n/a















64 State - Future Grants

0 n/a
















Subtotal - Federal/State Grants

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0





n/a
















Passenger Facility Charges


n/a















65 PFCs - $3.00 Application Approved

$0 n/a















66 PFCs - $3.00 Application Submitted

0 n/a















67 PFCs - $3.00 Future Application(s)

0 n/a















68 PFCs - $4.50 Application Approved

0 n/a















69 PFCs - $4.50 Application Submitted

0 n/a















70 PFCs - $4.50 Future Application(s)

0 n/a















71 PFCs - Future Level
[assumed level] 0 n/a
















Subtotal - PFCs

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Debt



















72 Revenue Bonds - MII Approved

$0 n/a















73 Revenue Bonds - MII pending

0 n/a















74 General Obligation - Authority in Place

0 n/a















75 General Obligation - Authority Pending

0 n/a















76 Other Debt - Authority in Place

0 n/a















77 Other Debt - Authority Pending

0 n/a
















Subtotal - Debt

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















78 Airport Funds

$0 n/a















79 Tenant or Third-Party Funds

0 n/a






































Total - All Funding Sources

$0 n/a
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Cumulative Sources




$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















Unmet Funding Needs


Totals

Prior Years 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028


























$0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0



Summary Funding Sources




















Discretionary - LOI Request $0



















Other AIP funds $0



















Other Federal funding $0



















State grants 0



















PFCs $0



















Bonds $0



















Other $0



















Total $0









































Funding Status




















Discretionary - LOI Request $0



















Grants awarded $0



















Approved PFCs $0



















Approved bonds $0



















Future grants $0



















Future PFCs $0



















Future bonds $0



















Other $0



















Total $0
















Capital Costs and Annual Cashflow Requirements - Other Capital Plans














































Totals as %
Prior Years FFY-2015 FFY-2016 FFY-2017 FFY-2018 FFY-2019 FFY-2020 FFY-2021 FFY-2022 FFY-2023 FFY-2024 FFY-2025 FFY-2026 FFY-2027 FFY-2028

Professional Services

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Land Acquisition

0 #DIV/0!
0 0 0 $0 0 0 0 0 0 0 0 0 0 0 0

Runways

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Airside

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Terminal

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Landside

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Infrastructure

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Summary

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Cumulative Needs




$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















Capital Funding Sources - Other Capital Plans














































Totals as %
Prior Years FFY-2015 FFY-2016 FFY-2017 FFY-2018 FFY-2019 FFY-2020 FFY-2021 FFY-2022 FFY-2023 FFY-2024 FFY-2025 FFY-2026 FFY-2027 FFY-2028

Federal and State Grants




















Entitlements - Grants Awarded

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Entitlements - Future Grants

0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Discretionary - LOI Request

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Discretionary - Other - Awarded

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Discretionary - Other - Future Grants

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Discretionary - Noise - Awarded

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Discretionary - Noise - Future Grants

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

State Apportionment - Grants Awarded

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

State Apportionment - Future Grants

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Federal (non-AIP) - Grants Awarded

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Federal (non-AIP) - Future Grants

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

State - Grants Awarded

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

State - Future Grants

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Subtotal - Federal/State Grants

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Passenger Facility Charges




















PFCs - $3.00 Application Approved

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PFCs - $3.00 Application Submitted

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PFCs - $3.00 Future Application(s)

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PFCs - $4.50 Application Approved

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PFCs - $4.50 Application Submitted

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PFCs - $4.50 Future Application(s)

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PFCs - Future Level
[assumed level] 0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Subtotal - PFCs

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Debt




















Revenue Bonds - MII Approved

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Revenue Bonds - MII pending

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

General Obligation - Authority in Place

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

General Obligation - Authority Pending

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Debt - Authority in Place

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Debt - Authority Pending

0 #DIV/0!
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Subtotal - Debt

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Airport Funds

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Tenant or Third-Party Funds

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0























Total - All Funding Sources

$0 #DIV/0!
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Cumulative Sources




$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0






















Unmet Funding Needs


Totals

Prior Years 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028


























$0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

























Summary Funding Sources




















Discretionary - LOI Request $0



















Other AIP funds $0



















Other Federal funding $0



















State grants 0



















PFCs $0



















Bonds $0



















Other $0



















Total $0









































Funding Status




















Discretionary - LOI Request $0



















Grants awarded $0



















Approved PFCs $0



















Approved bonds $0



















Future grants $0



















Future PFCs $0



















Future bonds $0



















Other $0



















Total $0

















Sheet 3: Alternative Disbursement Sched

LOI Application Financial Template















Data Entry Sheet #2

















































Airport Sponsor Information
































[insert airport name]















[insert three-letter identifier]















[insert city and state]















[insert hub category - Large, Medium, Small or Nonhub]















[insert airport owner/operator -- e.g., "City of East Rutherford"]















[insert submission date]
































Alternative Disbursement Proposal(s)


































































OFFICIAL REQUEST Totals
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028

















Discretionary - LOI disbursement schedule $0
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0



















































ALTERNATIVE A
































Discretionary - LOI disbursement schedule $0














Change (if any) in LOI Discretionary funding 0














Impact on costs and/or other funding sources

[insert explanation]



























































ALTERNATIVE B
































Discretionary - LOI disbursement schedule $0














Change (if any) in LOI Discretionary funding 0














Impact on costs and/or other funding sources

[insert explanation]



























































ALTERNATIVE C
































Discretionary - LOI disbursement schedule $0














Change (if any) in LOI Discretionary funding 0














Impact on costs and/or other funding sources

[insert explanation]



























































ALTERNATIVE D
































Discretionary - LOI disbursement schedule $0














Change (if any) in LOI Discretionary funding 0














Impact on costs and/or other funding sources

[insert explanation]


























Sheet 4: Project-Level Data Entry

LOI Application Financial Template

















Data Entry Sheet #3























































Airport Sponsor Information




































[insert airport name]

















[insert three-letter identifier]

















[insert city and state]

















[insert hub category - Large, Medium, Small or Nonhub]

















[insert airport owner/operator -- e.g., "City of East Rutherford"]

















[insert submission date]




































Individual Project Components







































Part of Proposed Action?
Include in BCA?

LOI Project Proposed Action Overall Capital Plan
Professional Services Land Acquisition Runways Other Airside Terminal Landside Infrastructure

Cost
Y/N
Y/N Justification for Requested Exclusion

Example: Taxiway F Rehabilitation $1,800,000
N
N Will occur with or without Night Vision Program
$0 $0 $1,800,000







Example: EIS - Night Vision Program $4,600,000
Y
N Costs incurred regardless of outcome, and already funded
$0 $4,600,000 $4,600,000







[insert project by project]






$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0















$0 $0 $0







Summary $0
$0
$0 $0
$0 $0 $0
$0 $0 $0 $0 $0 $0 $0

Sheet 5: Summary Analytical Sheet

LOI Application Financial Template






























Airport Sponsor Information






























1 [insert airport name]













2 [insert three-letter identifier]













3 [insert city and state]













4 [insert hub category - Large, Medium, Small or Nonhub]













5 [insert airport owner/operator -- e.g., "City of East Rutherford"]













6 [insert submission date]



















































































































































Discretionary - LOI Request $0













Other AIP funds $0













Other Federal funding $0













State grants 0













PFCs $0













Bonds $0













Other $0














$0





























Funding Status














Discretionary - LOI Request $0













Grants awarded $0













Approved PFCs $0













Approved bonds $0













Future PFCs $0













Future bonds $0













Other $0













Total $0
































Summary Cashflow Needs $0













0 0







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