CERTS Application

CERTS Application Tabs

1. Instructions for Filling Out This Application

2. Documents You Will Need to Upload to Complete the Application

3. Definition of Terms

4. Company Information

5. Demographic Information on Company Owners/Principals (Optional)

6. Eligibility Information

7. Other Federal Funds Received in Response to COVID-19

8. Bank Account Information

9. Upload Tax Documents

10. Certification and Signature

TAB 1: INSTRUCTIONS FOR FILLING OUT THIS APPLICATION

OMB Control Number 1505-XXXX
PAPERWORK REDUCTION ACT NOTICE
The information collected in this application will be used by the U.S. Government to process requests for financial support. 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. 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, U.S. Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address.

The CERTS application consists of 10 sections that are listed in the tabs on the left side of the screen.

Sections 1 through 3 provide instructions and background information.

Sections 4 through 10 have a series of questions to answer or fields to populate. Please answer each question or enter information in each field in accordance with the instructions in the section. As you progress through the application, you will also be required to upload certain documents – for a complete list of the documents please see the next section “Documents You Will Need to Upload to Complete the Application.”

After completing a section, you must click the NEXT button at the bottom right corner of the screen to save your responses and advance to the next section.

At any time, you may also click the SAVE button on the bottom right corner of the screen to save an application in progress. Once an application in progress is saved, you may return to it later to complete it or change it before the application deadline.

A CERTS application must be linked one-to-one to a Federal tax return, such that the official name, TIN, principal business activity code, and total annual revenues that will be entered into the application form will match the same values on the corresponding tax return. Therefore, references to “you” and “your company” in the application refer to the specific entity with that official name on the application and the tax return. Please refer to the CERTS “Frequently Asked Questions” document on the CERTS homepage [link to https://home.treasury.gov/certs/] for more details on how applications should be submitted for different corporate and operating structures, including structures with affiliated companies under common ownership.

The last section “Certification and Signature” will require an authorized representative of your company to certify and electronically sign the application using a DocuSign electronic signature. After you finish filling out the application, an email with a DocuSign link will be sent to the email address of the authorized company official you identify allowing them to electronically sign and submit the application.

After the application is completed, electronically signed, and submitted successfully, the primary contact person listed in the application will receive an automated confirmation email from Treasury.

For additional information on CERTS, please see the CERTS guidelines and Frequently Asked Questions on the CERTS hompage. [link to CERTS homepage https://home.treasury.gov/certs/]

If you have a specific question about how to complete this application, you may email [email protected] or call 877-398-5862. To be considered for a CERTS grant, you must complete and submit your application by the deadline of 11:59 PM ET on July xx, 2021.

TAB 2: DOCUMENTS YOU WILL NEED TO UPLOAD TO COMPLETE THE APPLICATION

To complete the application, you will need to upload the following documents. If you do not upload the following documents, your application will not be considered complete and cannot be processed.

ALL COMPANIES

• Annual Income Tax Returns. All companies must upload a copy of their Federal income tax returns filed in their own name and Taxpayer Identification Number (TIN) for both 2019 and 2020, as specified below.

• For C-Corporations, upload IRS Form 1120

• For S-Corporations, upload IRS Form 1120-S

• For partnerships, upload IRS Form 1065

• For self-employed individuals, upload Schedule C (IRS Form 1040)

• For LLCs: Use one of the above

Your CERTS application must be linked one-to-one to your Federal tax return, such that the name, TIN, principal business activity code, and total annual revenues you enter into the application form match the same values on the corresponding tax return that you upload.

If you are a common parent company or holding company that files a consolidated tax return representing one or more affiliates that provide transportation services eligible under CERTS grant, you must complete this application using the name, TIN, and total revenues of the common parent company and upload the consolidated tax return.

If your company does not have its Federal income tax return for 2020 because you have applied for an extension to file, then in lieu of your 2020 Federal income tax return you must upload a copy of your application for an extension to file (IRS Form 7004 for businesses or IRS Form 4868 for self-employed individuals) or, if you filed the application for extension electronically, a copy of the IRS’s electronic acknowledgement.

AND

• Q1 2020 Employer’s Quarterly Federal Tax Return. All companies must upload a complete copy of IRS Form 941 for Q1 2020 filed in their own name and TIN.

If you do not have a Form 941 in your own company name and TIN because you contract with a third-party to process your payroll and report your payroll taxes, such as a payroll service provider or a Professional Employer Organization (PEO), then in lieu of the IRS Form 941 you must upload a completed form letter [link to form letter] signed by an authorized representative of your service provider attesting to your total number of employees and your total compensation for Q1 2020.

If for any reason your company filed more than one IRS Form 941 for the quarter (e.g., you are applying in the name of a parent company with a consolidated income tax return, but submitted separate IRS Form 941s for the subsidiary operating and payroll corporations), then you must upload copies of all of your company’s IRS Form 941s for Q1 2020.

PASSENGER VESSEL COMPANIES

• United States Coast Guard (USCG) Certificate of Inspection (COI). Passenger vessel companies must upload a copy of a current USCG-issued COI for up to three passenger vessels. If your company operates three or more passenger vessels, you must upload three COIs (representing your three largest vessels if you have more than three). If your business operates only one or two passenger vessels, you must upload COIs for each of your one or two vessels.

If your company does not have a USCG-issued COI because it operates passenger vessels on non-federal waters regulated only by a State or local jurisdiction, then your company must upload a current State- or local-issued operating certificate or permit in lieu of a USCG-issued COI.

PILOTAGE COMPANIES

• Authorizing Document. All pilotage companies must upload a copy of the current operating license or other document issued to their company by the State pilot commission, board, or oversight body stating that the pilotage company is recognized and authorized to facilitate the provision of pilotage services.

SCHOOL BUS COMPANIES

• Certificate of Insurance. All school bus companies must upload a current certificate of insurance that evidences liability coverage for their school bus company under SIC Code 4151 (School Buses), NAICS Code 485410 (School Bus Services), or comparable school bus industry insurance code, with a description of operations or vehicles referencing school bus transportation of students. An acceptable “current” certificate includes both active coverage and coverage that has been suspended pending resumption of services after the pandemic, but does not include any certificate indicating canceled or lapsed coverage. (This document must be uploaded for school bus companies to submit a complete application. The CERTS program guidelines published on May 6, 2021, did not have this requirement. However, the CERTS program guidelines have been subsequently updated to include this requirement.)

TAB 3: DEFINITION OF TERMS

The terms defined below are used in various parts of the application. These definitions supplement and interpret certain terms in the CERTS Act. Please take time to review these definitions, and refer to this section as necessary to complete your application fully and accurately.

“Debt on major equipment” means the principal amount of debt owed to a creditor for “major equipment,” including loans, capital leases, and that portion of the outstanding balance of a master credit agreement that is secured by “major equipment.” “Debt on major equipment” does not include any amounts owed on operating leases, for accrued interest or fees, or that portion of the outstanding balance of a master credit agreement that is secured by assets other than “major equipment.”

“In operation” means that a company is fully licensed, registered, and authorized to provide transportation services, is capable of generating sales or receipts from transportation services, and is not dissolved, out of business, or in a bankruptcy case filed under the U.S. Bankruptcy Code.

“Major equipment” means a motorcoach or over-the-road bus, a school bus, a passenger vessel or small passenger vessel, or a pilotage support vessel, consistent with the other definitions in this section. Major equipment does NOT include any other type of equipment, facilities, or assets.

“Motorcoach transportation service provider” or “motorcoach company” means a private sector company, registered as an interstate carrier at the federal level or an intrastate carrier at the State level, whose principal business is providing passenger transportation services using one or more buses with an elevated passenger deck located over a baggage compartment (commonly known as an “over-the-road bus”) for local and intercity fixed-route service, commuter service, and/or charter or tour service (including tour or excursion services that includes features in addition to bus transportation, such as meals, lodging, admission to points of interest or special attractions, or the services of a guide).

“Passenger vessel transportation service provider” or “passenger vessel company” means a private sector company whose principal business is carried out using one or more passenger vessels or small passenger vessels of the United States (as each is defined in 46 USC § 2101) that (a) are for hire with a capacity of 6 to 2,400 passengers and (b) have a U.S. Coast Guard (USCG) issued Certificates of Inspection (COI) (or a State-issued operating certificate or permit)].

“Pilotage transportation service provider” or “pilotage company” means a private sector company, organization, group, or association whose principal business is providing pilotage services regulated by a State in accordance with 46 U.S.C. § 8502, and does not mean an operator of vessels providing towing or other tug assist services.

“Principal business” or “principal business activity” means the business activity from which a company derives the highest percentage of its total sales or receipts as reported to the IRS on its tax returns.

“School bus transportation service provider” or “school bus company” means a private sector company whose principal business is providing student transportation services under contract to a school, school district, or State department of education to carry students to and from school and/or to and from education-related events, activities, and competitions, using one or more school buses as defined in 49 CFR § 571.3. School buses must be designed for carrying more than 10 persons, and do not include buses designed or sold for operation as a common carrier in urban transportation.

TAB 4: COMPANY INFORMATION

Please enter the following information about your company.

NAME. Please enter your official company name as set forth in the charter or other legal document that created your company. Do not enter an unofficial operating name, a “doing business as” name, or any other fictitious name, regardless of whether the alternative name has been filed with a State government. Your official company name must match the legal name on the annual tax return for your company. (If you are part of a corporate family that includes one or more affiliated companies that provide eligible transportation services and your tax returns are filed on a consolidated basis by a common parent corporation for multiple subsidiary corporations, you should use the official name of the common parent corporation.)

• Official Company Name [alphanumeric field]

BUSINESS TIN (EIN or SSN). Please enter your 9-digit business TIN, which may be an Employer Identification Number (EIN), or if you are a sole proprietor may be your Social Security Number (SSN). Please check this box if you are a sole proprietor and the business TIN you enter is your SSN. [check box]

The business TIN you enter must match the TIN on the annual tax return for your company.

• Business TIN [9-digit numeric field]

BUSINESS ADDRESS. Please enter your company address. No P.O. Box addresses are allowed. The address must be the official address for your official company name as reported on the annual tax return for your company.

• Street [alphanumeric field – reject P.O. Boxes]

• City [alpha field]

• State [drop down inc. territories]

• Zip Code (5 digits) [5-digit numeric field – reject if alpha or not 5 digits]

• Zip +4 Code [4-digit numeric – reject if alpha or not 4 digits]

You may look up your Zip +4 Code by entering your address in the U.S. Postal Service Zip Code tool here. (add link to USPS address lookup tool)

PRIMARY CONTACT. Please enter information for your primary contact person if we need to discuss this application with you.

• Name [alphanumeric]

• Title [alphanumeric]

• Phone [3-3-4 numeric]

• Email [email format check]

TAX RETURN TYPE. Please select the IRS Form your company files annually based on the tax treatment of your organization from the drop-down menu. If you are an LLC, please select the category that matches the IRS tax form you file.

• Annual Tax Return Type [drop down selections: C-Corp – IRS Form 1120, S-Corp – IRS Form 1120-S, Partnership – IRS Form 1065, Sole Proprietorship – Schedule C (IRS Form 1040)]

CONSOLIDATED TAX RETURNS. If you are part of a corporate family that includes one or more affiliated companies that provide eligible transportation services and your tax returns are filed on a consolidated basis by a common parent corporation for multiple subsidiary corporations, then please check this box. [check box] For companies that file tax returns on a consolidated basis, all questions in this application referring to “you” and “your company” refer to the combined activities of the consolidated company filing the tax return.

EMPLOYEES ON MARCH 1, 2020. Please enter the total number of employees, including all full-time, part-time, and temporary/seasonal employees, your company had on March 1, 2020. [numeric field]

ANNUAL AVERAGE EMPLOYEES IN 2019. Please enter the annual average number of employees (including full-time, part-time, and temporary/seasonal employees) your company had in calendar year 2019. To calculate your annual average number of employees for 2019, average the number of employees reported quarterly in 2019 to the IRS in your four Employer’s Quarterly Federal Tax Returns (IRS Form 941).

• Annual Average Number of Employees 2019 [numeric field]

TYPE OF ELIGIBLE TRANPORTATION SERVICE PROVIDER. Please identify your company’s type of transportation service using the drop-down menu. CERTS grants are available to motorcoach companies, school bus companies, passenger vessel companies, and pilotage companies only. If you are not one of these four types of companies, you are not eligible for a CERTS grant.

If your company provides more than one type of eligible transportation service under the same TIN and tax return (e.g., motorcoach services and school bus services in the same corporate entity), please select the transportation type that represents the largest portion of your annual revenues.

If your corporate structure includes different companies under common ownership providing different types of eligible transportation services under different TINs and separate income tax returns (e.g., Company A providing motorcoach services and Company B providing school bus services with separate tax returns), you must submit a separate application for each eligible company filing an income tax return.

• Type of Transportation Service Provider [drop down selections: Motorcoach Company, School Bus Company, Passenger Vessel Company, Pilotage Company]

COMPANY OWNERS WITH 20% EQUITY. Please identify all owners with 20% or more of the equity of the company applying. Click the ADD button to enter additional names if there is more than one owner with 20% equity. If your company has no owners with 20% equity, leave these fields blank.

• Owner Name [alphanumeric field] – Title [alphanumeric field] – Ownership % [numeric field – TIN (EIN or SSN) [9 digit numeric] -- [ADD BUTTON] (display these fields as one row)

DEBT ON MAJOR EQUIPMENT DECEMBER 31, 2019. Please enter the total principal amount of debt on major equipment your company owed on December 31, 2019.

“Debt on major equipment” means the principal amount of debt owed to a creditor for “major equipment,” including loans, capital leases, and that portion of the outstanding balance of a master credit agreement that is secured by “major equipment.” “Debt on major equipment” does not include any amounts owed on operating leases, for accrued interest or fees on, or that portion of the outstanding balance of a master credit agreement that is secured by assets other than “major equipment.”

“Major equipment” means a motorcoach or over-the-road bus, a school bus, a passenger vessel or small passenger vessel, or a pilotage support vessel. Major equipment does NOT include any other type of equipment, facilities, or assets.

• Principal Amount of Debt on Major Equipment on December 31, 2019 [currency field / numeric]

DUNS Number. You do not need a DUNS number to receive a CERTS grant. However, if you have a DUNS number, please enter it here. If you do not have a DUNS number, leave this field blank.

• DUNS Number [9-digit numeric field – reject if alpha or less than 9 digits] (allow for unpopulated field)

SAM.GOV. You do not need to be registered in SAM.gov to receive a CERTS grant. However, please indicate whether you are registered in SAM.gov.

• Registered in SAM.gov? [Y/N]

PARENTS, SUBSIDIARIES, AFFILIATES. Please enter the official company name and Business TIN (EIN) of all corporate parents, subsidiaries, and other affiliates of your company, if any. Parents, subsidiaries, and affiliates means any company that directly or indirectly controls, is controlled by, or is under common control with, your company. If a particular parent, subsidiary, or other affiliate of your company had a total workforce of more than 500 employees (including all full-time, part-time, and temporary/seasonal employees) on March 1, 2020, you must check the box in the right column. Click the ADD button to enter an additional row if your company has more than one parent, subsidiary, or other affiliate.

• Official Company Name [alphanumeric field] – Business TIN (EIN) [numeric 9 digits] – Relationship [drop down menu: parent, subsidiary, affiliate] – 500+ Employees? [check box] [ADD BUTTON] (display these fields as one row)

TAB 5: SOCIOECONOMIC INFORMATION (Optional)

Below you have the option to indicate if your company is minority-owned, woman-owned, and/or veteran-owned. Answering any of these questions is optional and for program reporting purposes only.

• Is your company a minority-owned business? [Y/N]

(user response is optional)

• Is your company a woman-owned business? [Y/N]

(user response is optional)

• Is your company a veteran-owned business? [Y/N]

(user response is optional)

TAB 6: ELIGIBILITY INFORMATION

Please answer the following questions to allow Treasury to assess your company’s eligibility for a CERTS grant.

ORGANIZED IN THE U.S. Is your company established or organized in the United States or pursuant to Federal law? [Y/N]

U.S. OPERATIONS. Does your company have significant operations and a majority of employees based in the United States? [Y/N]

STATUS ON MARCH 1, 2020. Was your company in operation on March 1, 2020? “In operation” means that your company was fully licensed, registered, and authorized to provide transportation services, was capable of generating sales or receipts from transportation services, and was not dissolved, out of business, or in any kind of bankruptcy case filed under the U.S. Bankruptcy code on March 1, 2020. [Y/N]

(if no to any of the three questions above) You answered “no” to this question. Therefore, you are not eligible for a CERTS grant. To be eligible for a CERTS grant, you must be able to answer “yes” to this question and to certify the accuracy of your “yes” answer. (prevent completion of application)

CURRENT CHAPTER 7 BANKRUPTCY CASE. Is your company in a pending bankruptcy case filed under or converted to Chapter 7 of the U.S. Bankruptcy Code? [Y/N]

SUSPENSION AND DEBARMENT. Is your company, or any owner of your company, currently suspended or debarred, or proposed to be suspended or debarred, from receiving Federal contracts or assistance by any Federal agency? [Y/N]

FELONY. For any felony involving fraud, bribery, embezzlement, or false statement in a Federal loan or financial assistance application, is your company or any owner of your company currently subject to an indictment, and within the last 5 years, has your company or any owner of your company (1) been convicted, (2) pleaded guilty, (3) pleaded nolo contendere, or (4) commenced any form of parole (including probation before judgement)? [Y/N]

INCARCERATION. Is any owner of your company currently incarcerated or, for any felony, currently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction? [Y/N]

(if yes to any of the 4 questions above) You answered “yes” to this question. Therefore, you are not eligible for a CERTS grant. To be eligible for a CERTS grant, you must be able to answer “no” to this question and to certify the accuracy of your “no” answer. (prevent completion of application)

CURRENT CHAPTER 11 OR CURRENT CHAPTER 13 BANKRUPTCY CASE. If your company is in a pending Chapter 11 bankruptcy case filed on or after March 1, 2020, or if you are a sole proprietorship in a pending Chapter 13 bankruptcy case filed on or after March 1, 2020, you remain eligible for a CERTS grant. Are you in a pending Chapter 11 or Chapter 13 bankruptcy case ? [Y/N]

(if yes) Please provide the following information on your case.

• Date of Bankruptcy Filing [date field]

• Type (Chapter) of Pending Bankruptcy Case [dropdown: 11, 13]

• Bankruptcy court [alphanumeric field]

• Case number [alphanumeric field]

LOST REVENUES PERCENTAGE. To be eligible for a CERTS grant, you must be able to certify a revenue loss of 25 percent or more on an annual, calendar year basis from 2019 to 2020 as a direct or indirect result of COVID-19.

To calculate your revenue loss, please enter your 2019 and 2020 annual revenues from your tax returns. You indicated that your company filed an [IRS Form 1120 / IRS Form 1120-S / IRS Form 1065 / Schedule C (IRS Form 1040] for your Federal Income Tax Returns. (render as appropriate based on answer to question on Tax Return Type) Therefore, please enter in the fields below the amount on line 1c on IRS Form 1120 / line 1c on IRS Form 1120-S / line 1c on IRS Form 1065 / line 3 on IRS Form 1040 Schedule C (if you file multiple Schedule C forms on the same Form 1040, you must enter the sum across all of them). (render as appropriate based on answer to question on Tax Return Type)

If your company in 2020 was the result of a corporate merger or acquisition of two or more independent companies that existed separately and filed their own tax returns in 2019, then please check this box [check box] and enter the combined revenues the companies reported on their separate tax returns for 2019.

If you cannot enter the revenue amount from your 2020 Federal income tax return because you have applied for an extension to file and have not yet filed your 2020 return, then please check this box. [check box]

(if box checked then render these two additional paragraphs before the input fields)

Since you have not filed your Federal income tax return for 2020, please enter the amount you currently expect to enter on [line 1c on IRS Form 1120 / line 1c on IRS Form 1120-S / line 1c on IRS Form 1065 / line 3 on IRS Form 1040 Schedule C (if you file multiple Schedule C forms on the same Form 1040, you must enter the sum across all of them)] when you complete and file your 2020 return. (render as appropriate based on answer to question on Tax Return Type)

Later in this application, you will be required to certify this amount for 2020 revenues and upload information substantiating that you applied for an extension to file your 2020 return. The amount you enter for your 2019 revenues must match the amount reported on your 2019 tax return.

• 2019 Revenues [dollar numeric field]

• 2020 Revenues [dollar numeric field] [BUTTON: CLICK HERE TO CALCULATE YOUR LOST REVENUES PERCENTAGE]

• Your Revenue Loss Percentage [auto calculate percentage and display to user]

(if less than 25 percent – for all cases/users)

Based on the amounts your entered, your annual revenue loss was less than 25 percent. Therefore, you are not eligible for a CERTS grant. (prevent completion of application)

PRINCIPAL BUSINESS ACTIVITY CODE. Please enter the 6-digit Principal Business Activity Code you entered on your company’s 2019 income tax returns. The principal business activity code is in [Line 2a on Page 4/Schedule K of IRS Form 1120 / Item B at the top of Page 1 of IRS Form 1120-S / Item C at the top of Page 1 of IRS Form 1065 / Item B at the top of Page 1 of Schedule C of IRS Form 1040] (render as appropriate based on answer to question on Tax Return Type)

• Principal Business Activity Code [numeric field 6 digits] [BUTTON: CLICK HERE TO CONFIRM THE CODE YOUE ENTERED]

(note: PBAC entered should have validation against IRS list of PBAC that meet CERTS eligibility)

(if PBAC is not qualified transportation code) The Principal Business Activity Code you entered does not appear to relate to the services provided by an eligible transportation service provider, i.e., a motorcoach company, school bus company, passenger vessel company, or pilotage company. Before proceeding with the application, please make sure you have entered the correct code as it was entered on your 2019 tax return, and then proceed with completing the application.

(add for pilotage companies – there is only one case for pilotage companies)

PILOTAGE OPERATING LICENSE. To validate your eligibility as a pilotage company / association, please upload a copy of the operating license or other document issued to your pilotage company by a state pilot commission, board, or oversight body stating that you are recognized and authorized to facilitate the provision of pilotage services..

(add for passenger vessel companies BASE CASE)

To validate your eligibility as a passenger vessel company, please provide the following information and documents.

VESSEL NAMES, OFFICIAL NUMBERS, AND CERTIFICATES OF INSPECTION. You must provide the vessel name and official number as it appears on a USCG-issued Certificate of Inspection, for up to three passenger vessels operated by your company. You must also upload a copy of the current USCG-issued Certificate(s) of Inspection for the vessels. Alternatively, if you do not have a USCG-issued COI because you operate passenger vessels on non-Federal waters regulated only by a State or local jurisdiction, then you must provide a State or local registration hull number in lieu of an official number and upload a copy of a current State- or- local-issued operating certificate or permit in lieu of a USCG-issued COI.

Does your company have USCG-issued COIs, or does it operate on non-Federal waters and have State- or local-issued operating certificates or permits? [dropdown with 2 choices: USCG-issued COIs / State- or local-issued certificate or permit]

(if USCG)

Please enter the vessel name and official number, and upload the USCG-issued COI, for up to three passenger vessels operated by your company. If your company operates three or more passenger vessels you must provide the information for three vessels. If your company operates only one or two passenger vessels, you must provide the information for each of your one or two vessels.

1. Vessel Name [alphanumeric field] – Official Number [alphanumeric] – Upload COI

2. Vessel Name [alphanumeric field] – Official Number [alphanumeric] – Upload COI

3. Vessel Name [alphanumeric field] – Official Number [alphanumeric] – Upload COI

(display the above numbered lines as one row for each of the three)

(at least one row must be completed, but not all three)

(Vessel Number submitted needs back-end comparison to USCG spreadsheet of Vessel Numbers)

(if State or local certificate or permit)

Please enter the vessel name and the State or local registration hull number, and upload the State- or local-issued operating certificate or permit, for up to three passenger vessels operated by your company. If your company operates three or more passenger vessels you must provide the information for three vessels. If your company operates only one or two passenger vessels, you must provide the information for each of your one or two vessels.

4. Vessel Name [alphanumeric field] – Registration Hull Number [alphanumeric] – Upload Certificate/Permit

5. Vessel Name [alphanumeric field] – Registration Hull Number [alphanumeric] – Upload Certificate/Permit

6. Vessel Name [alphanumeric field] – Registration Hull Number [alphanumeric] – Upload Certificate/Permit

(display the above numbered lines as one row for each of the three)

(at least one row must be completed, but not all three)

NUMBER OF TOTAL VESSELS BY TYPE. Please enter the current number of vessels operated by your company by type. If you do not have any vessels under a particular type, enter zero.

• Passenger Vessels [numeric field]

• Cargo Vessels (all types) [numeric field]

• All Other (Tug/Tow, Offshore Services, Oceanographic, etc.) [numeric field]

(add for passenger vessel companies CONSOLIDATED TAX RETURN CASE)

To validate your eligibility as a passenger vessel company, please provide the following information and documents.

VESSEL NAMES, OFFICIAL NUMBERS, AND CERTIFICATES OF INSPECTION. You indicated you filed a consolidated tax return for multiple subsidiary companies. You must provide the vessel name and official number as it appears on a USCG-issued Certificate of inspection for up to three passenger vessels operated by your common parent corporation or your subsidiary corporations included in your consolidated tax returns. You must also upload a copy of the current USCG-issued Certificate(s) of Inspection for the vessels. Alternatively, if your corporate family does not have USCG-issued COIs because you operate passenger vessels on non-Federal waters regulated only by a State or local jurisdictions, then you must provide State or local registration hull numbers in lieu of an official number and upload a copy of current State- or- local-issued operating certificates or permits in lieu of USCG-issued COIs.

Does your company have USCG-issued COIs, or does it operate on non-Federal waters and have State- or local-issued operating certificates or permits? [dropdown with 2 choices: USCG-issued COIs / State- or local-issued certificate or permit]

(if USCG)

Please enter the vessel name and official number, and upload the USCG-issued COI, for up to three passenger vessels operated by your consolidated company, including parent and subsidiaries. If your consolidated company operates three or more passenger vessels you must provide the information for three vessels. If your company operates only one or two passenger vessels, you must provide the information for each of your one or two vessels.

7. Vessel Name [alphanumeric field] – Official Number [alphanumeric] – Upload COI

8. Vessel Name [alphanumeric field] – Official Number [alphanumeric] – Upload COI

9. Vessel Name [alphanumeric field] – Official Number [alphanumeric] – Upload COI

(display the above numbered lines as one row for each of the three)

(at least one row must be completed, but not all three)

(Vessel Number submitted needs back-end comparison to USCG spreadsheet of Vessel Numbers)

(if State or local certificate or permit)

Please enter the vessel name and the State or local registration hull number, and upload the State- or local-issued operating certificate or permit, for up to three passenger vessels operated by your consolidated company, including parent and subsidiaries. If your consolidated company operates three or more passenger vessels you must provide the information for three vessels. If your company operates only one or two passenger vessels, you must provide the information for each of your one or two vessels.

10. Vessel Name [alphanumeric field] – Registration Hull Number [alphanumeric] – Upload Certificate/Permit

11. Vessel Name [alphanumeric field] – Registration Hull Number [alphanumeric] – Upload Certificate/Permit

12. Vessel Name [alphanumeric field] – Registration Hull Number [alphanumeric] – Upload Certificate/Permit

(display the above numbered lines as one row for each of the three)

(at least one row must be completed, but not all three)

NUMBER OF TOTAL VESSELS BY TYPE. Please enter the current number of vessels operated by your consolidated company, including parent and subsidiaries, by type. If you do not have any vessels under a particular type, enter zero.

• Passenger Vessels [numeric field]

• Cargo Vessels (all types) [numeric field]

• All Other (Tug/Tow, Offshore Services, Oceanographic, etc.) [numeric field]

(for motorcoach companies BASE CASE)

To validate your eligibility as a motorcoach company, please provide the following information and documents.

USDOT NUMBER. Please enter your current USDOT Number. If you are an intrastate carrier that does not have a USDOT number, please check this box [check box]

• USDOT Number [numeric field up to 7 digits max]

(note: USDOT# submitted needs back-end comparison to DOT spreadsheet of USDOT#s)

(if box checked – delete / grey out USDOT field and present the following)

You indicated that you are an intrastate carrier that does not have a USDOT Number. Therefore, you must enter your current State Motor Carrier Registration Number to confirm your eligibility as a motorcoach company. You must also enter the name of the State department or agency that issued the number.

• State Registration Number [alphanumeric field]

• State Department or Agency that Issued the Number [alphanumeric field]

(review team to cross check with state/territory in address)

NUMBER OF PASSENGER MOTOR VEHICLES BY TYPE. Please enter the current total number of commercial passenger motor vehicles operated by your company by type. If you do not have any vehicles under a particular type, enter zero.

• Motorcoaches [numeric field]

• School Buses (all sizes) [numeric field]

• Buses (all sizes) [numeric field]

• Passenger Vans (all sizes) [numeric field]

• Limousines (all sizes) [numeric field]

(for motorcoach companies CONSOLIDATED TAX RETURN CASE)

USDOT NUMBERS. You indicated you filed a consolidated tax return for multiple subsidiary corporations. Please enter up to three current USDOT Numbers issued to your common parent corporation or your subsidiary corporations included in your consolidated tax return. Only up to three USDOT Numbers are needed even if you have more than three subsidiary corporations with numbers.

1. USDOT Number [numeric field up to 7 digits max]

2. USDOT Number [numeric field up to 7 digits max]

3. USDOT Number [numeric field up to 7 digits max]

(at least one row must be completed, but not all three)

(note this alternative case for consolidated filers does not need the State registration number alternative)

NUMBER OF PASSENGER MOTOR VEHICLES BY TYPE. Please enter the current total number of commercial passenger motor vehicles your consolidated company, including parent and subsidiaries, operates by type. If you do not have any vehicles under a particular type, enter zero.

• Motorcoaches [numeric field]

• School Buses (all sizes) [numeric field]

• Buses (all sizes) [numeric field]

• Passenger Vans (all sizes) [numeric field]

• Limousines (all sizes) [numeric field]

(for school bus companies BASE CASE)

To validate your eligibility as a school bus company, please answer the following questions and upload the required document(s).

PROOF OF STUDENT TRANSPORTATION. Please upload a current certificate of insurance that clearly evidences your company has liability coverage as a school bus company under SIC Code 4151 (School Buses), NAICS Code 485410 (School Bus Services), or comparable school bus industry code, with a description of operations or vehicles including school bus transportation of students. An acceptable “current” certificate includes both active coverage and coverage that has been suspended pending resumption of services after the pandemic, but does not include any certificate indicating canceled or lapsed coverage.

SCHOOL BUS VEHICLE IDENTIFICATION. Please enter the Vehicle Identification Number (VIN), license plate, and model year for up to three school busses (buses for carrying students designed for carrying more than 10 passengers) operated by your company. If your company operates three or more school busses, you must provide VINs, license plates, and model years for three school busses. If your company operates only one or two school busses, you must provide the VINs, license plates, and model years for each of your one or two school busses. .

1. VIN [alphanumeric – reject if not 17] – Confirm VIN [reject if mismatch] – License Plate [alphanumeric] – Confirm License Plate [alphanumeric reject if mismatch] – License Plate State [drop down inc. territories] – Model Year [numeric 4 digits]

2. VIN [alphanumeric – reject if not 17] – Confirm VIN [reject if mismatch] – License Plate [alphanumeric] – Confirm License Plate [alphanumeric reject if mismatch] – License Plate State [drop down inc. territories] – Model Year [numeric 4 digits]

3. VIN [alphanumeric – reject if not 17] – Confirm VIN [reject if mismatch] – License Plate [alphanumeric] – Confirm License Plate [alphanumeric reject if mismatch] – License Plate State [drop down inc. territories] – Model Year [numeric 4 digits]

(at least one row must be completed, but not all three)

NUMBER OF STUDENT PASSENGER MOTOR VEHICLES BY TYPE. Please enter the current number of passenger motor vehicles your company operates to transport students, using the following categories. If you do not have any vehicles under a particular category, enter zero.

• School Buses for 10+ passengers [numeric field]

• All Other Buses (all types and sizes) [numeric field]

• Passenger Vans (all sizes) [numeric field]

• Cars [numeric field]

(must have entry in all fields, even if 0)

NAME OF A CUSTOMER SCHOOL. Please enter the name of the primary or largest school, school district, or State or local department of education with whom you had / have a contract for the provision of school bus services to transport students during or after 2019.

• Name of school, school district, or State or local department [alphanumeric field]

USDOT NUMBER (if applicable). If your school bus company has a current USDOT Number, please enter it here. If your school bus company does not have a USDOT Number, leave this field blank and proceed to the next question.

• USDOT Number [numeric field up to 7 digits max]

(allow this to be left blank)

STATE SCHOOL BUS COMPANY REGISTRATION / BUSINESS LICENSE (if applicable). If your school bus company has a State-issued registration number or business license number that uniquely identifies your company and authorizes the commercial operation of school buses, please enter it here with the name of the State department or agency that issued the number. If your school bus company does not have such a State-issued number, leave these fields bland and proceed to the next question.

• State Registration Number / Business License Number [alphanumeric field]

• State Department or Agency that Issued the Number [alphanumeric field]

(allow these fields to be left blank)

(for school bus companies CONSOLIDATED TAX RETURN CASE)

To validate your eligibility as a school bus company, please answer the following questions and upload the required document(s).

PROOF OF STUDENT TRANSPORTATION. You indicated you filed a consolidated tax return for multiple subsidiary corporations. Please upload up to three current certificates of insurance that clearly evidence liability coverage for school bus companies in your consolidated company. The certificate(s) should include SIC Code 4151 (School Buses), NAICS Code 485410 (School Bus Services), or comparable school bus industry code, with a description of operations or vehicles including school bus transportation of students. An acceptable “current” certificate includes both active coverage and coverage that has been suspended pending resumption of services after the pandemic, but does not include any certificate indicating canceled or lapsed coverage. Only up to three certificates are needed even if you have more than three subsidiary corporations with separate certificates.

1.
2.
3.

(at least one document must be uploaded, but not all three)

SCHOOL BUS VEHICLE IDENTIFICATION. Please enter the Vehicle Identification Number (VIN), license plate, and model year for three school busses (buses for carrying students designed for carrying more than 10 passengers) operated by your consolidated company, including parent and subsidiaries. Only three entries are required.

1. VIN [alphanumeric – reject if not 17] – Confirm VIN [reject if mismatch] – License Plate [alphanumeric] – Confirm License Plate [alphanumeric reject if mismatch] – License Plate State [drop down inc. territories] – Model Year [numeric 4 digits]

2. VIN [alphanumeric – reject if not 17] – Confirm VIN [reject if mismatch] – License Plate [alphanumeric] – Confirm License Plate [alphanumeric reject if mismatch] – License Plate State [drop down inc. territories] – Model Year [numeric 4 digits]

3. VIN [alphanumeric – reject if not 17] – Confirm VIN [reject if mismatch] – License Plate [alphanumeric] – Confirm License Plate [alphanumeric reject if mismatch] – License Plate State [drop down inc. territories] – Model Year [numeric 4 digits]

(must have 3 entries)

NUMBER OF STUDENT PASSENGER MOTOR VEHICLES BY TYPE. Please enter the current number of passenger motor vehicles your consolidated company, including parent and subsidiaries, operates to transport students, using the following categories. If your consolidated company does not have any vehicles under a particular category, enter zero.

• School Buses for 10+ passengers [numeric field]

• All Other Buses (all types and sizes) [numeric field]

• Passenger Vans (all sizes) [numeric field]

• Cars [numeric field]

(must have entry in all fields, even if 0)

NAMES OF CUSTOMER SCHOOLS. Please enter the names of up to three schools, school districts, or State or local departments of education with whom your consolidated company had / has a contract for the provision of school bus services to transport students during or after 2019. Only up to three names are needed even if you have more than three subsidiary corporations and/or contracts for the provision of services.

1. Name of school, school district, or State or local department [alphanumeric field]

2. Name of school, school district, or State or local department [alphanumeric field]

3. Name of school, school district, or State or local department [alphanumeric field]

(at least one row must be completed, but not all three)

USDOT NUMBERS (if applicable). If your common parent corporation or your subsidiary school bus companies included in your consolidated tax return have current USDOT Numbers, please enter up to three USDOT Numbers here. Only up to three USDOT Numbers are needed even if you have more than three subsidiary corporations with numbers. If you do not have USDOT Numbers, leave these fields blank and proceed to the next question.

1. USDOT Number [numeric field up to 7 digits max]

2. USDOT Number [numeric field up to 7 digits max]

3. USDOT Number [numeric field up to 7 digits max]

(allow these fields to be left blank)

STATE SCHOOL BUS COMPANY REGISTRATIONS / BUSINESS LICENSES (if applicable). If your common parent corporation or your subsidiary school bus companies have State-issued registration numbers or business license numbers that uniquely identify the companies and authorize the commercial operation of school buses, please enter up to three such numbers and the names of the State departments or agencies that issued the numbers. Only up to three entries are needed even if you have more than three subsidiary school bus companies with numbers. If you do not have such State-issued numbers, leave these fields bland and proceed to the next question.

1. State Registration / Business License Number [alphanumeric field]

State Department or Agency that Issued the Number [alphanumeric field]

2. State Registration / Business License Number [alphanumeric field]

State Department or Agency that Issued the Number [alphanumeric field]

3. State Registration / Business License Number [alphanumeric field]

State Department or Agency that Issued the Number [alphanumeric field]

(allow these fields to be left blank)

TAB 7: OTHER FEDERAL FUNDS RECEIVED IN RESPONSE TO COVID-19

FEDERAL FINANCIAL ASSISTANCE PROGRAMS. You must disclose the total amount of Federal financial assistance you received up to the date of this application, if any, under other Federal grant, loan, and tax credit programs in response to COVID-19.

• Did you receive assistance under the Paycheck Protection Program (PPP)? [Y/N]

• (if yes) Please enter the total PPP amount received and a loan number

PPP Loan Amount(s) [numeric field] – Loan Number [alphanumeric field]

(note: Name/PPP loan number submitted needs back-end comparison to SBA spreadsheets of PPP loans)

• Did you receive assistance under the Economic Injury Disaster Loan (EIDL) program? [Y/N]

• (if yes) Please enter the total amount received and a loan number

EIDL Loan Amount(s) [numeric field] – Loan Number [alphanumeric field]

(note: Name/EIDL loan number submitted needs back-end comparison to SBA spreadsheets of EIDL loans)

• Did you claim tax credits as an eligible employer under the Employee Retention Credit due to COVID-19?

• (if yes) Please enter the total amount of Employee Retention Credits claimed

Employee Retention Credits [numeric field]

• Did you receive assistance as a subrecipient grantee of a transit agency or State agency, from funding appropriated to the Federal Transit Administration (FTA) in response to COVID-19? Such assistance or compensation may have come from a supplemental COVID-19 appropriation for the Section 5311(f) Intercity Bus Program, the Section 5307 Urbanized Area Formula Grant, or another FTA program. [Y/N]

• (if yes) Please enter the total amount of grant funding received under FTA programs.

FTA Grant Amount(s) [currency field]

• Did you receive assistance as a subrecipient grantee from funding appropriated to the U.S. Department of Education in response to COVID-19? Such assistance may have come from a supplemental COVID-19 appropriation for the Education Stabilization Fund, which includes but is not limited to the Elementary and Secondary School Relief Fund. [Y/N]

• (if yes) Please enter the total amount of grant funding received through Education Stabilization Fund programs.

Education Stabilization Fund Grant Amount(s) [currency field]

• Did you receive financial assistance under any other Federally funded grant or loan program in response to COVID-19? [Y/N]

• (if yes) Please enter the name of the program and the total amount received. If you received financial assistance under more than one other Federally funded grant or loan program, click the ADD button to enter an additional programs and amounts.

Name of Program [alphanumeric] – Assistance Amount [numeric] [ADD BUTTON]

(display these fields as one row)

FEDERAL CONTRACTS. You must disclose the total amount of any other Federal funds you received, if any, as compensation for providing services under a contract, subcontract, or service agreement that was funded by appropriations in response to COVID-19.

Did you enter into or amend any other contract, subcontract, or service agreement on or after March 27, 2020, under which you received funds appropriated to a Federal agency in response to COVID-19? [Y/N]

(if yes) You must provide the following information about the contract, subcontract, or service agreement under which you were paid Federal funds. If you were paid under more than one contract, subcontract, or agreement, click the ADD button to enter additional contracts, subcontracts, or agreements.

• Name of Federal agency acquiring the service or providing the funding [alphanumeric field]

• Total amount of funds paid or committed to your company [numeric field – dollars]

• Description of your services under the contract or agreement [open text field]

[ADD BUTTON]

(if a sole proprietor)

SOLE PROPRIETORS. Sole proprietors must disclose the total amount of Federally funded unemployment benefits they have received, if any, in response to COVID-19. Sole proprietors do NOT need to disclose the receipt of traditional Unemployment Insurance benefits funded by a State government.

Did you receive unemployment benefits under any of the four programs listed below, which were funded by the Federal Government in response to COVID-19? [Y/N]

1. Pandemic Emergency Unemployment Compensation (PEUC) – additional weeks of benefits to individuals who exhausted the full number of weeks of traditional Unemployment Insurance benefits in their State.

2. Pandemic Unemployment Assistance (PUA) – unemployment benefits provided to individuals who are not eligible for traditional Unemployment Insurance benefits or PEUC and are unemployed / unable / unavailable to work because of specific COVID-19 related reasons.

3. Federal Pandemic Unemployment Compensation (FPUC) – supplemental weekly payment that was originally $600 and subsequently $300 to provide individuals with additional amounts above their unemployment benefit amounts.

4. Mixed Earners Unemployment Compensation (MEUC) – supplemental weekly payment of $100 to provide individuals who earned a certain amount of self-employment income in the most recent taxable year with additional amounts above their unemployment benefit amounts.

(if yes) Please enter the total amount of Federally funded unemployment benefits received under all the programs above since January 2020. Do not include the base amounts you received for traditional Unemployment Insurance benefits, which are funded through a State government.

• Total Amount of Federally-funded unemployment benefits [numeric field – currency]

(OCIO please add up all lines under FEDERAL FINANCIAL ASSISTANCE PROGRAMS and if applicable SOLE PROPRIETORS and put in summary report to compare with 2019 revenues. To be clear, the FEDERAL CONTRACTS total is excluded from the sum and comparison)

TAB 8: BANK ACCOUNT INFORMATION

Please provide the following information about the financial institution and bank account to which you want your CERTS grant to be paid electronically. Payments will be made by Direct Deposit through the Automated Clearing House (ACH).

• Financial Institution Name [alphanumeric field]

• Financial Institution Address [alphanumeric field]

• Financial Institution Telephone Number [10 digit numeric 3-3-4]

• Routing Transit Number [9 digit numeric – reject if alpha characters or less than 9 digits]

• Confirm Routing Transit Number [9 digit numeric – reject if alpha, less than 9 digits, or mismatch]
  
  

• Account Number [numeric only – reject if alpha]

• Confirm Account Number [numeric only – reject if alpha, or mismatch]

• Is this account Checking or Savings? Please select one. (required selection boxes for one or the other)

TAB 9: UPLOAD TAX DOCUMENTS

(if box NOT checked for no 2020 returns under “Lost Revenues” above, then render the following section)

2019 AND 2020 FEDERAL INCOME TAX RETURNs. You indicated that, based on the tax treatment of your company, you filed an [IRS Form 1120 / IRS Form 1120-S / IRS Form 1065 / Schedule C (IRS Form 1040] for your Federal income tax returns. Please upload copies of your company’s [IRS Form 1120 / IRS Form 1120-S / IRS Form 1065 / Schedule C (IRS Form 1040)] for 2019 and for 2020. (render as appropriate based on answer to question on Tax Return Type) The TIN on your Federal income tax returns must match the TIN you provided for your company earlier in this application.

2019 Federal Tax Return
2020 Federal Tax Return

(if box checked for no 2020 returns under “Lost Revenues” above, then render the following two sections instead of the text above)

2019 FEDERAL INCOME TAX RETURNs. You indicated that, based on the tax treatment of your business, you filed an [IRS Form 1120 / IRS Form 1120-S / IRS Form 1065 / Schedule C (IRS Form 1040] for your Federal income tax returns. Please upload a copy of your company’s [IRS Form 1120 / IRS Form 1120-S / IRS Form 1065 / Schedule C (IRS Form 1040)] for 2019. (render as appropriate based on answer to question on Tax Return Type) The TIN on your 2019 Federal income tax returns must match the TIN you provided for your company earlier in this application.

2019 Federal Tax Return

DOCUMENT IN LIEU OF 2020 FEDERAL INCOME TAX RETURN. You indicated your company does not have its Federal income tax form for 2020 because you have applied for an extension to file. In lieu of uploading your 2020 Federal income tax return you must (1) upload a copy of your application for an extension to file (IRS Form 7004 for businesses or IRS Form 4868 for self-employed individuals) or, if you filed the application for extension electronically, a copy of the IRS’s electronic acknowledgement, and (2) confirm that you have internal company income statements or other financial statements to clearly substantiate your total annual revenues for 2020 to be made available to Treasury or Federal auditors upon request.

• Please upload either a copy of your application for an extension to file (IRS Form 7004 for businesses or IRS Form 4868 for self-employed individuals) or, if you filed the application for extension electronically, a copy of the IRS’s electronic acknowledgement.

• Please confirm that you have internal company income statements or other financial statements, to be made available upon request, to clearly substantiate your total annual revenues for 2020. ☐ (check box)

(if applicant checked box for 2019 merger/acquisition, add this additional section to the tab so they can upload more 2019 documents)

ADDITIONAL 2019 FEDERAL INCOME TAX RETURNS. You indicated that your current company is the result of a merger or acquisition of two or more independent companies that filed their own tax returns in 2019. Please upload copies any additional 2019 tax returns of the pre-merger companies to validate the total 2019 revenues that should be associated with your post-merger company. Click the ADD button if you need to upload returns for more than one pre-merger company.

Additional 2019 Federal Tax Return

[ADD]

(if box checked indicating a common parent corporation filing a consolidated tax return, then render this section also)

2019 AND 2020 AFFILIATIONS SCHEDULES. You indicated that you are part of a corporate family that includes one or more affiliated companies that provide eligible transportation services and that your tax returns are filed on a consolidated basis by a common parent corporation. Therefore, please upload copies of your IRS Forms 851 Affiliations Schedules that identify the subsidiary corporations.

2019 IRS Forms 851
2020 IRS Forms 851

(941 base case)

Q1 2020 EMPLOYER’S QUARTERLY FEDERAL TAX RETURN (IRS FORM 941). You must enter the following data and upload a copy of your IRS Form 941 for Q1 2020. The name and TIN on your IRS Form 941 must match the name and TIN you provided for your company earlier in this application.

If you cannot upload an IRS Form 941 in your own company name and TIN because you contract with a third-party to process your payroll and report your payroll taxes, such as a payroll service provider or a Professional Employer Organization (PEO), then please check this box. (check box)

Please enter the number of employees on Line 1 of your Q1 2020 Form 941 [numeric] Please enter the wages, tips, and other compensation on Line 2 of your Q1 2020 Form 941 [numeric]
Please upload a copy of your Q1 2020 IRS Form 941

(if box checked, render fields below instead)

You indicated you do not have IRS Form 941 in your own name and TIN because you use a third-party service provider. Therefore, please enter the data below, and in lieu of uploading your own Q1 2020 IRS Form 941, you must upload a completed form letter [link to form letter] signed by an authorized representative of your service provider attesting to your total number of employees and their total compensation for Q1 2020. If necessary, please save your application, download the form letter, have your service provider complete the form letter, and return to the application when you can upload the completed form letter.

Please enter the number of employees your service provider reported for you to the IRS for Q1 2020 (Line 1 of Form 941) [numeric] Please enter the wages, tips, and other compensation your service provider reported for you to the IRS for Q1 2020 (Line 2 of Form 941) [numeric]
Please upload the required form letter from your third-party service provider in lieu of your own Q1 2020 IRS Form 941

(941 case of CONSOLIDATED FEDERAL TAX RETURN)

Q1 2020 EMPLOYER’S QUARTERLY FEDERAL TAX RETURN (IRS FORM 941). You must enter the following data as reported on your IRS Form 941 for Q1 2020. You indicated that you are part of a corporate family that includes one or more affiliated companies that provide eligible transportation services and that your tax returns are filed on a consolidated basis by a common parent corporation. Therefore, your answers must reflect the combined values of the consolidated entity. If you have multiple IRS Form 941s for Q1 2020 because your subsidiary corporations filed separate quarterly returns, please sum the values across all of them.

• Please enter the number of employees on Line 1 of your Q1 2020 Form 941 [numeric]

• Please enter the wages, tips, and other compensation on Line 2 of your Q1 2020 Form 941 [numeric]

You must upload a copy of your IRS Form 941 for Q1 2020. If you have multiple IRS Form 941s for Q1 2020 because your subsidiary companies filed separate quarterly returns, you must upload a copy of each IRS Form 941 linked to your consolidated entity.

Your uploaded IRS Form 941s must show official company names and TINs. If you cannot upload a particular IRS Form 941 showing an official company name and TIN because you or your subsidiary contracts with a third-party to process your payroll and report your payroll taxes, such as a payroll service provider or a Professional Employer Organization (PEO), you must upload a completed form letter [link to form letter] signed by an authorized representative of your service provider in lieu of the IRS Form 941. If necessary, please save your application, download the form letter, have your service provider complete the form letter, and return to the application when you can upload the completed form letter.

Please upload copies of all your Q1 2020 IRS Form 941s

(allow for multiple document uploads)

TAB 10: CERTIFICTION AND SIGNATURE

An authorized company official must sign your application using a DocuSign electronic signature.

By electronically signing and submitting this application, the company and its identified authorized official certify under penalty of perjury that:

1) all the information provided in this application is true and correct;
2) the company has and shall retain documentation and records to support the information provided in this application; and
3) the company shall make such supporting documents and records available upon request.

Please enter the name, title, and email address of your company’s authorized official who will electronically sign your application.

• Name of Authorized Official [alphanumeric field]

• Title of Authorized Official [alphanumeric field]

• Email Address of Authorized Official [email field]

After you click the button below SUBMIT APPLICATION FOR AUTHORIZED SIGNATURE, an email will be sent to your authorized official with your completed application and a DocuSign link to electronically sign the application.

[SUBMIT APPLICATION FOR AUTHORIZED SIGNATURE]

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). Treasury may refer any allegations of fraud, waste, or abuse in connection with CERTS to the Treasury Inspector General.

(render the following on a new page after submitting for signature)

Thank you for submitting your company’s application for signature. An email with a DocuSign link has been sent to your authorized company official to electronically sign the application.

Your application is not complete or official until Treasury receives the electronically signed application. Please make sure your authorized official retrieves and responds to the email with the DocuSign electronic signature link.

This form letter may be completed and uploaded, in lieu of uploading an IRS Form 941 “Employer’s Quarterly Federal Tax Return,” if your company cannot supply an IRS Form 941 in its own name and TIN because you contract with a third-party to process your payroll and report your payroll taxes, such as a payroll service provider (e.g., ADP) or a Professional Employer Organization (PEO).

The letter must be completed and signed by an authorized representative of your service provider.

Confirmation of Employer’s Quarterly Federal Tax Return Data

in connection with the

Coronavirus Economic Relief for Transportation Services (CERTS) Act

To be completed by Payroll Service Providers (PSP), Certified Professional Employer Organizations (CPEO), and other authorized agents.

To the U.S. Department of the Treasury:

I am an authorized representative of the following company:

Name of PSP / CPEO / Agent:

My company acts as a third party to file IRS Form 941 data for the following CERTS applicant:

Name of Company:

TIN of Company:

For Q1 2020, the CERTS applicant identified above reported to the IRS the following number of employees and total wages, tips, and other compensation:

Number of Employees:

Wages, Tips, and Other Compensation:

Sincerely,

Signature: _____________________________­­­­­_____

Name:

Title:

Date:

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