Form AMJP 1A.2.3 AMJP 1A.2.3 AMJP Recipient Report of Replacement in the Eligible Rep

Form AMJP-1A.2.3

OMB CONTROL NUMBER: 2106-0048
EXPIRATION DATE: 11/30/2021

FORM AMJP-1A.2.3
AMJP RECIPIENT REPORT TO USDOT OF REPLACEMENT IN THE ELIGIBLE
EMPLOYEE GROUP

PAPERWORK REDUCTION ACT PUBLIC BURDEN 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 2106-0048. Public reporting for this collection of information is estimated to be
approximately 120 minutes 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 to obtain or
retain a benefit (pursuant to the American Rescue Plan Act of 2021 (ARPA), Public Law (P.L.)
117-2, § 7201-7202). Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, Department of Transportation, OST-S-83, 1200 New Jersey
Avenue S.E., Washington, DC 20590.

OMB CONTROL NUMBER: 2106-0048
EXPIRATION DATE: 11/30/2021

Form AMJP-1A.2.3

FORM AMJP-1A.2.3
AMJP RECIPIENT REPORT TO USDOT OF REPLACEMENT IN THE ELIGIBLE
EMPLOYEE GROUP
AMJP Recipient Business Name
AMJP Agreement Number

69A345

AMJ0

Effective Date of Employee
Departure
Effective Date of Employee
Addition to EEG
per (Select one)

Difference in Compensation
Amount

Payroll Period Length

Narrative Explanation of Replacement:

Provide a brief description of the replacement action, including the reason for making the change to the Eligible
Employee Group (EEG). Include the separated individual’s and replacing employee’s EEG member IDs
consistent with the current AMJP Recipient Notification to USDOT of EEG Composition (Form AMJP-1A.6.5).
Do not include any personally identifiable information about employees; redact that information as necessary.

Example: Employee ID #1003 retired on September 30, 2021. Employee ID #1024 is moved into the
EEG effective October 1, 2021. Employee ID #1024’s compensation is $50 more per month than
Employee ID #1003, so we do not foresee a need to reduce the EEG’s Total Compensation Level for
the remaining period of performance.

Attachments:

Provide a list identifying all attachments. Attach documentation of the difference in compensation, including
documentation of the affected wages, salaries, and benefits included in the total base compensation for the affected
employees. Do not include any personally identifiable information about employees.

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OMB CONTROL NUMBER: 2106-0048
EXPIRATION DATE: 11/30/2021

Form AMJP-1A.2.3

Certification:
I certify under penalty of perjury that the information above and attached is true and correct, and
I have authority to submit this information to the USDOT on behalf of the Recipient.
I acknowledge that false, fictitious, or fraudulent information, or the omission of any material
fact, may subject me to criminal penalties, civil penalties, or both. (See 18 U.S.C. 287; 18 U.S.C.
1001; 31 U.S.C. 3729; 31 U.S.C. 3802).
Signature

Date

Name of Signing Official

Title of Signing Official

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