5100-128 Agreement on State Sponsorship and Airport Sponsor Oblig

U.S. Department
of Transportation
Federal Aviation
Administration

FAA Form 5100-128, Agreement on State Sponsorship and Airport
Sponsor Obligations – Airport Improvement Program
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 5100-128

DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION

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

Agreement on State Sponsorship and Airport Sponsor Obligations
Airport Improvement Program
Airport:
Sponsor:
hereinafter called the “Airport Sponsor”
Associated City:
hereinafter called the “Associated City”
Project Description:

hereinafter called the “Project”
State:

hereinafter called the “State”

In accordance with 49 USC § 47105 the Airport Sponsor hereby consents to the Project
sponsorship by the State for the Project at the above airport and associated city.

Sponsor’s Certification
I assure and certify, for the project identified herein, the Airport Sponsor will comply with terms,
conditions, and assurances contained in the Project Application submitted to the Federal Aviation
Administration by the state and to Grant Agreement Conditions required by the Federal Aviation
Administration. A copy of the Project Application Assurances and Grant Agreement Conditions is
attached and made part of this Agreement on State Sponsorship and Airport Sponsor Obligations.
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:
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.

FAA Form 5100-128 (8/20) SUPERSEDES PREVIOUS EDITION

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