Payroll Support Application Form

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.