Payroll Support Application Form

CARES Act Air Carrier Loan and Payroll Support Programs

1505-NEW Air Carrier Payroll Support Application Form_20200330_651p

Payroll Support Application & Agreement (Sections 4112 & 4113)

OMB: 1505-0263

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DELIBERATIVE PRE-DECISIONAL SENSITIVE WORKING DRAFT

3-30-20


OMB Approved No. 1505-0263

Expiration Date: 09/30/2020


PAYROLL SUPPORT APPLICATION FORM

for Air Carriers and Contractors


March 30, 2020


To receive approval of their applications as soon as possible, applicants should submit their completed application materials not later than 11:59 p.m. EDT on April 2, 2020 to [email protected]. Applications received after April 2 will be considered, but may not receive approval as quickly. Applications received after 11:59 p.m. EDT on April 27, 2020 may not be considered for approval by the Treasury Department, but the Treasury Department may, in its discretion and subject to the availability of funds, consider such applications for approval.


The definitions of the terms contained in this application appear in Division A, Title IV, Subtitle B of the Coronavirus Aid, Relief and Economic Security Act, Pub. L. 116-136 (Mar. 27, 2020) (the “Act”), and in the Guidelines and Application Procedures for Payroll Support to Air Carriers and Contractors under Division A, Title IV, Subtitle B of the Act (the Guidelines).



APPLICANT INFORMATION


Applicant Name



Applicant’s Taxpayer ID Number



Applicant’s Address



Contact Person Name



Contact Person Title



Contact Person Phone



Contact Person E-mail







APPLICANT TYPE


Type of applicant (choose one):



Passenger Air Carrier


Cargo Air Carrier


Contractor


If a contractor to a carrier or airport, identify the type of firm or function (choose all that apply):



Catering


Loading and Unloading of Property on Aircraft



Assistance for Disabled Passengers


Security


Airport Ticketing and Check-In



Ground-Handling of Aircraft


Aircraft Cleaning, Sanitation, Waste Removal



Other (specify)


If a contractor to a carrier or airport, identify the primary or largest carrier or airport to which services are provided:


Name of Carrier or Airport





Identify any parent companies and affiliates of the applicant:


Names of Parent Companies and Affiliates











FINANCIAL INSTITUTION INFORMATION

(For electronic payment. The account listed below should be the same account used by the applicant to make tax payments to the IRS.)


Routing Transit Number



Applicant’s Account Number



Checking or savings (circle one)

Financial Institution Name



Financial Institution Address



Financial Institution Telephone Number





EMPLOYMENT LEVELS


Identify the annual average number of U.S. employees for the applicant in 2019, and the number of U.S. employees the applicant has involuntarily furloughed, laid off, or subjected to other involuntary employee reductions after March 1, 2020.


Average Number of Employees 2019


Involuntary Reductions After March 1, 2020




AWARDABLE AMOUNTS


The maximum potential amount of payroll assistance that may be awarded to an applicant is equal to the compensation paid by the applicant to its employees from April 1, 2019, through September 30, 2019, as determined by the Treasury Department in its sole discretion, referred to as the “awardable amount.” Compensation includes salaries, wages, bonuses, and similar payments.


For air carriers that report salaries and benefits to the U.S. Department of Transportation (DOT) under 14 CFR part 241: the awardable amount is based on the amounts reported to DOT, and the air carrier should not complete the table below.


For air carriers and contractors that do NOT report salaries and benefits to DOT under 14 CFR part 241: the applicant MUST complete the following table, which shall be considered a sworn financial statement of the applicant, and supply supporting documentation as the Secretary of the Treasury may require.


In completing the table below, amounts must reflect ONLY employees as defined in the Act and the Guidelines.


Month

Salaries and Wages

Benefits

Other Compensation

Monthly Total

April 2019






May 2019






June 2019






July 2019






August 2019






September 2019






Total




TAXPAYER PROTECTION


Each applicant must identify financial instruments to be issued to the Secretary that, in the sole determination of the Secretary, provide appropriate compensation to the Federal Government for the provision of payroll support. Such financial instruments may include warrants, options, preferred stock, debt securities, notes, or other financial instruments issued by the applicant.


Each applicant must provide information in the following table that describes in sufficient detail its proposed financial instruments under this requirement. Each applicant will be notified whether the proposed financial instruments are acceptable before application approval.


Applicant Name:


Type of the Financial Instrument:



Amount, Value, or Price of the Financial Instrument, as Appropriate:



Seniority/Priority of the Financial Instrument Relative to Other Equity/Debt of Applicant:



Term or Duration of the Financial Instrument, if Applicable:



Other Terms and Conditions that Could Affect the Value of the Financial Instrument:




ADDITIONAL INFORMATION


Applicants MUST include with their application their completed IRS Form 941 “Employers Quarterly Federal Tax Return” covering the period April 1, 2019 to September 30, 2019.




CERTIFICATION



I certify under penalty of perjury that the information and certifications provided in the application and its attachments are true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties. (18 U.S.C. §§ 287, 1001; 31 U.S.C. §§ 3729, 3802).


Name of First Certifying Official



Title of First Certifying Official



Signature of First Certifying Official



Name of Second Certifying Official



Title of Second Certifying Official



Signature of Second Certifying Official



Applicant Name



Date








PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is two hours per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.

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