Form AMJP 1A.6.4 AMJP 1A.6.4 AMJP Recipient Request for Interim Payment

Form AMJP-1A.6.4

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

FORM AMJP-1A.6.4
AMJP RECIPIENT REQUEST FOR INTERIM PAYMENT

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 150 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.6.4

FORM AMJP-1A.6.4
AMJP RECIPIENT REQUEST FOR INTERIM PAYMENT
AMJP Recipient Business Name
AMJP Agreement Number

69A345

AMJ0

Request Amount
Allowable Costs Incurred to Date
As of Date

Amount

The request amount and all prior AMJP payments from USDOT must not exceed 90% of the
Estimated Public Contribution.
Attachments:

Provide a list identifying all attachments. Attach documentation supporting the allowable costs incurred to date,
consistent with the current AMJP Recipient Notification to USDOT of EEG Composition (Form AMJP-1A.6.5)
and any notices of actions affecting the eligible employee group or replacements in the eligible employee group.
Do not include any personally identifiable information about employees; redact that information as necessary.

Certification:
I certify that the allowable costs incurred to date were incurred in compliance with the terms of
the agreement identified by the AMJP Agreement Number above and that the Recipient remains
in compliance with that agreement, including the mandatory reporting and notice provisions in
sections 2.2, 2.3, 2.4, and 9.5 of Attachment A to that agreement.
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