AMJP 1A.2.4 Recipient Report to USDOT of employment action Affecting

Form AMJP-1A.2.4

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

FORM AMJP-1A.2.4
AMJP RECIPIENT REPORT TO USDOT OF EMPLOYMENT ACTION NOT
AFFECTING 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.2.4

FORM AMJP-1A.2.4
AMJP RECIPIENT REPORT TO USDOT OF EMPLOYMENT ACTION
NOT AFFECTING THE ELIGIBLE EMPLOYEE GROUP
AMJP Recipient Business Name
AMJP Agreement Number

69A345

AMJ0

Date of Employment Action
Nature of Employment Action
(select all that apply)

□ Layoffs
□ Furloughs

Total Number of Affected Employees
Narrative Description of Employment Action:

Provide a description of the employment action. Do not include any personally identifiable information about
employees; redact that information as necessary.

Example: On December 1, 2021, ABC Aerospace announced a mandatory furlough affecting all
hourly and salaried employees other than those included in the AMJP Eligible Employee Group.
Affected employees will be required to take 4 furlough days (unpaid) between January 1, 2022 and
June 30, 2022. Management is required to take 12 furlough days during the same period. Medical
insurance coverage is not impacted by these furlough days.

Narrative Justification for the Employment Action:

Provide a narrative justification of the employment action. Do not include any personally identifiable information
about employees; redact that information as necessary.

Example: This action is made necessary by the continued slow recovery of top-line revenues and new
orders for parts and services. Management has limited the action to a six-month period based on
optimistic forecasts for recovery during the second and third quarters of calendar year 2022.

Page 1 of 2

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

Form AMJP-1A.2.4

Attachments:

Provide a list identifying all attachments. Attach documentation as needed to support the narrative description or
justification above. Do not include any personally identifiable information about employees; redact that information
as necessary.

Certification:
I certify that the employment action described above did not include or result in the Recipient
Involuntarily laying off, furloughing, or reducing the pay rate of any Employee in the Eligible
Employee Group.
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

Page 2 of 2