5100-110 Request for FAA Approval of Agreement for Transfer of En

U.S. Department
of Transportation
Federal Aviation
Administration

FAA Form 5100-110, Request for FAA Approval of Agreement for
Transfer of Entitlements
Paperwork Reduction Act 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 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours 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 under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. 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, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX
76177-1524.

FAA Form 5100-110

OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 6/30/2023

U.S. Department of Transportation
Federal Aviation Administration

Request for FAA Approval of Agreement for Transfer of Entitlements
In accordance with 49 USC § 47117(c)(2),
Name of Transferring Sponsor:
hereby waives receipt of the following amount of funds apportioned to it under 49 USC § 47114(c) for
the: Name of Transferring Airport (and LOCID):

(

)

for each fiscal year listed below:
Entitlement Type
(Passenger, Cargo or
Nonprimary)

Fiscal Year

Total

N/A

Amount

The Federal Aviation Administration has determined that the waived amount will be made available to:
Name of Airport (and LOCID) Receiving Transferred Entitlements:
(

)

Name of Receiving Airport’s Sponsor:
a public use airport in the same state or geographical areas as the transferring airport for eligible projects
under 49 USC § 47104(a).
The waiver expires on the earlier of
apportioned funds lapses under 49 USC § 47117(b).

(date) or when the availability of

For the United States of America, Federal Aviation Administration:

Signature:
Name:
Title:
Date:

FAA Form 5100-110 (8/20) SUPERSEDES PREVIOUS EDITION

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Certification of Transferring Sponsor
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
Executed on this

day of

,

Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:

Signature of Sponsor’s Authorized Official:
Certificate of Transferring Sponsor’s Attorney
I,
, acting as Attorney for the Sponsor do hereby certify
that in my opinion the Sponsor is empowered to enter into the foregoing Agreement under the laws of the
state of
. Further, I have examined the foregoing Agreement
and the actions taken by said Sponsor and Sponsor’s official representative has been duly authorized and
that the execution thereof is in all respects due and proper and in accordance with the laws of the said
state and 49 USC § 47101, et seq.
Dated at
this

(City, State),
day of

,

Signature of Sponsor’s Attorney: ________________________________________________________

Submit by Email

FAA Form 5100-110 (8/20) SUPERSEDES PREVIOUS EDITION

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