DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION OMB NO. 2120-0569 11/30/2007 PART II PROJECT APPROVAL INFORMATION SECTION A Item 1. Does this assistance request require State, local, regional, or other priority rating? Name of Governing Body Priority Yes No Item 2. Does this assistance request require State, local advisory, educational or health clearances? Name of Agency or Board (Attach Documentation) Yes No Item 3. Does this assistance request require clearinghouse review in accordance with OMB Circular A-95? Yes (Attach Comments) No Item 4. Does this assistance request require State, local, regional, or other planning approval? Name of Approving Agency Yes No Item 5. Is the proposed project covered by an approved comprehensive plan? / / Check One: Yes No Item 6. Will the assistance requested serve a Federal installation? State Local Regional Location of plan Name of Federal Installation Federal Population benefiting from Project Yes No Item 7. Will the assistance requested be on Federal land or installation? Name of Federal Installation Location of Federal Land Percent of Project Yes No Item 8. Will the assistance requested have an impact or effect on the environment? See instructions for additional information to be provided. Yes No Item 9. Will the assistance requested cause the displacement of individuals, families, businesses, or farms? Yes No Item 10. Is there other related Federal assistance on this project previous, pending, or anticipated? Number of: Individuals Families Businesses Farms See instructions for additional information to be provided. Yes FAA Form 5100-100 (6-73) SUPERSEDES FAA FORM 5100-100 (9-03) Date No Page 2 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS PART II SECTION A Negative answers will not require an explanation unless the Federal agency requests more information at a later date. Provide supplementary data for all “Yes” answers in the space provided in accordance with the following instructions. Item 1. – Provide the name of the governing body establishing the priority system and the priority rating assigned to this project. Item 2. – Provide the name of the agency or board which issued the clearance and attach the documentation of status or approval. Item 3. – Attach the clearinghouse comments for the application in accordance with the instructions contained in Office of Management and Budget Circular No. A-95. If comments were submitted previously with a preapplication, do not submit them again but any additional comments received from the clearinghouse should be submitted with this application. Item 6. – Show the Federal population residing or working on the federal installation who will benefit from this project. Item 7. – Show the percentage of the project work that will be conducted on federally owned or leased land. Give the name of the Federal installation and its location. Item 8. – Briefly describe the possible beneficial and/or harmful impact on the environment because of the proposed project. If an adverse environmental impact is anticipated, explain what action will be taken to minimize the impact. Federal agencies will provide separate instructions if additional data is needed. Item 4. – Furnish the name of the approving agency and the approval date. Item 9. – State the number of individuals, families, businesses, or farms this project will displace. Federal agencies will provide separate instructions if additional data is needed. Item 5. – Show whether the approved comprehensive plan is State, local or regional, or if none of these, explain the scope of the plan. Give the location where the approved plan is available for examination and state whether this project is in conformance with the plan. Item 10. – Show the Federal Domestic Assistance Catalog number, the program name, the type of assistance, the status and amount of each project where there is related previous, pending, or anticipated assistance. Use additional sheets, if needed. Paperwork Reduction Act Statement: The information collected on this form allows sponsors of public use airports or public agencies to apply for one or more projects in a form prescribed by the Secretary of Transportation. Title 49, United States Code (U.S.C.), Section 47105, identifies the information required to apply for this program. The forms prescribed to meet this requirement are developed to provide a comprehensive format that allows sponsors to provide the data needed to evaluate the request for funds. The burden for each response is estimated to be 28 hours. Approved applications benefit the sponsor by providing Federal funding to protect the Federal interest in safety, efficiency, and utility of the Nation’s airport system. No assurance of confidentiality can be given since these become public records. If you wish to make any comments concerning the accuracy of this burden estimate or any suggestions for reducing this burden, send to Federal Aviation Administration, ARP-10, 800 Independence AVE, SW, Washington, DC 20591. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number, which is 2120-0569 for this collection. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20 American LegalNet, Inc. www.FormsWorkflow.com DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION OMB NO. 2120-0569 PART II – SECTION C The Sponsor hereby represents and certifies as follows: 1. Compatible Land Use. – The Sponsor has taken the following actions to assure compatible usage of land adjacent to or in the vicinity of the airport: 2. Defaults. – The Sponsor is not in default on any obligation to the United States or any agency of the United States Government relative to the development, operation, or maintenance of any airport, except as stated herewith: 3. Possible Disabilities. – There are no facts or circumstances (including the existence of effective or proposed leases, use agreements or other legal instruments affecting use of the Airport or the existence of pending litigation or other legal proceedings) which in reasonable probability might make it impossible for the Sponsor to carry out and complete the Project or carry out the provisions of Part V of this Application, either by limiting its legal or financial ability or otherwise, except as follows: 4. Consistency with Local Plans. – The project is reasonably consistent with plans (existing at the time of submission of this application) of public agencies that are authorized by the State in which the project is located to plan for the development of the area surrounding the airport. 5. Consideration of Local Interest. – It has given fair consideration to the interest of communities in or near where the project may be located. 6. Consultation with Users. In making a decision to undertake any airport development project under Title 49, United States Code, it has undertaken reasonable consultations with affected parties using the airport at which project is proposed. 7. Public Hearings. – In projects involving the location of an airport, an airport runway or a major runway extension, it has afforded the opportunity for public hearings for the purpose of considering the economic, social, and environmental effects of the airport or runway location and its consistency with goals and objectives of such planning as has been carried out by the community and it shall, when requested by the Secretary, submit a copy of the transcript of such hearings to the Secretary. Further, for such projects, it has on its management board either voting representation from the communities where the project is located or has advised the communities that they have the right to petition the Secretary concerning a proposed project. 8. Air and Water Quality Standards. – In projects involving airport location, a major runway extension, or runway location it will provide for the Governor of the state in which the project is located to certify in writing to the Secretary that the project will be located, designed, constructed, and operated so as to comply with applicable and air and water quality standards. In any case where such standards have not been approved and where applicable air and water quality standards have been promulgated by the Administrator of the Environmental Protection Agency, certification shall be obtained from such Administrator. Notice of certification or refusal to certify shall be provided within sixty days after the project application has been received by the Secretary. FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73) Page 3a American LegalNet, Inc. www.FormsWorkflow.com DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION OMB NO. 2120-0569 PART II – SECTION C (CONTINUED) 9. Exclusive Rights. – There is no grant of an exclusive right for the conduct of any aeronautical activity at any airport owned or controlled by the Sponsor except as follows: 10. Land. – (a) The sponsor holds the following property interest in the following areas of land* which are to be developed or used as part of or in connection with the Airport subject to the following exceptions, encumbrances, and adverse interests, all of which areas are identified on the aforementioned property map designated as Exhibit “A”: The Sponsor further certifies that the above is based on a title examination by a qualified attorney or title company and that such attorney or title company has determined that the Sponsor holds the above property interests. (b) The Sponsor will acquire within a reasonable time, but in any event prior to the start of any construction work under the Project, the following property interest in the following areas of land* on which such construction work is to be performed, all of which areas are identified on the aforementioned property map designated as Exhibit “A”: (c) The Sponsor will acquire within a reasonable time, and if feasible prior to the completion of all construction work under the Project, the following property interest in the following areas of land* which are to be developed or used as part of or in connection with the Airport as it will be upon completion of the Project, all of which areas are identified on the aforementioned property map designated as Exhibit “A”: *State character of property interest in each area and list and identify for each all exceptions, encumbrances, and adverse interests of every kind and nature, including liens, easements, leases, etc. The separate areas of land need only be identified here by the area numbers shown on the property map. FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100(4-76) Page 3b American LegalNet, Inc. www.FormsWorkflow.com DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION OMB NO. 2120-0569 PART III – BUDGET INFORMATION – CONSTRUCTION SECTION A – GENERAL 1. Federal Domestic Assistance Catalog No. 2. Functional or Other Breakout SECTION B - CALCULATION OF FEDERAL GRANT Use only for revisions COST CLASSIFICATION 1. Administration expense 2. Other architectural engineering fees 6. Project inspection fees 7. Land development 8. Relocation expenses 9. Relocation payments to individuals and businesses 10. Demolition and removal 11. Construction and project improvement 12. Equipment 13. Miscellaneous 14. Total (Lines 1 through 13) 15. Estimated Income (if applicable) 16. Net Project Amount (Line 14 minus 15) 17. Less: Ineligible Exclusions 18. Add: Contingencies 19. Total Project Amt. (Excluding Rehabilitation Grants) 20. Federal Share requested of Line 19 21. Add Rehabilitation Grants Requested (100 percent) 22. Total Federal grant requested (Lines 20 & 21) 23. Grantee share 24. Other shares 25. Total project (Lines 22, 23, & 24) $ Architectural engineering basic fees 5. $ Total Amount Required Land, structures, right-of-way 4. $ Adjustment + or (-) Preliminary expense 3. Latest Approved amount FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73) $ $ $ Page 4 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS PART III SECTION A. GENERAL 1. Show the Federal Domestic Assistance Catalog Number from which the assistance is requested. When more than one program or Catalog Number is involved and the amount cannot be distributed to the Federal grant program or catalog number on an over-all percentage basis, prepare a separate set of Part III forms for each program or Catalog Number. However, show the total amounts for all programs in Section B of the basic application form. 2. Show the functional or other categorical breakouts, if required by the Federal grantor agency. Prepare a separate set of Part III forms for each category. SECTION B. CALCULATION OF FEDERAL GRANT When applying for a new grant, use the Total Amount Column only. When requesting revisions of previously awarded amounts, use all columns. Line 1 - Enter amounts needed for administration expenses including such items as travel, legal fees, rental of vehicles and any other expense items expected to be incurred to administer the grant. Include the amount of interest expense when authorized by program legislation and also show this amount under Section E Remarks. Line 2 - Enter amounts pertaining to the work of locating and designing, making surveys and maps, sinking test holes, and all other work required prior to actual construction. Line 3 - Enter amounts directly associated with the acquisition of land, existing structures, and related right-of way. Line 4 - Enter basic fees for architectural engineering services. Line 5 - Enter amounts for other architectural engineering services, such as surveys, tests, and borings. Line 6 - Enter fees for inspection and audit of construction and related programs. Line 7 - Enter amounts associated with the development of land where the primary purpose of the grant is land improvement. Site work normally associated with major construction should be excluded from this category and shown on line 11. Line 8 - Enter the dollar amounts needed to provide relocation advisory assistance, and the net amounts for replacement (last resort) housing. Do not include relocation administration expenses on this Line; include them on Line 1. Line 9 - Enter the estimated amount of relocation payments to be made to displaced persons, business concerns, and non-profit organizations for moving expenses and replacement housing. Line 10 - Enter the gross salaries and wages of employees of the grantee who will be directly engaged in performing demolition or removal of structures from developed land. This line should show also the cost of demolition or removal of improvements on developed land under a third party contract. Reduce the costs on this line by the amount of expected proceeds from the sale of salvage, if so instructed by the Federal grantor agency. Otherwise, show the proceeds on Line 15. Line 11 - Enter amounts for the actual construction of, addition to, or restoration of a facility. Also, include in this category the amounts of project improvements such as sewers, streets, landscaping, and lighting. Line 12 - Enter amounts for equipment both fixed and movable exclusive of equipment used in construction. For example, include amounts for permanently attached lab oratory tables, built-in audio visual systems, movable desks, chairs, and laboratory equipment. Line 13 - Enter amounts for items not specifically mentioned above. Line 14 - Enter the sum of Lines 1-13. Line 15 - Enter the estimated amount of program income that will be earned during the grant period and applied to the program. Line 16 - Enter the difference between the amount on Line 14 and the estimated income shown on Line 15. Line 17 - Enter the amounts for those items which are a part of the project but not subject to Federal participation (See Section C, Line 26g, Column (1)). Line 18 - Enter the estimated amount for contingencies. Compute this amount as follows. Subtract from the net project amount shown on Line 16 the ineligible project exclusions shown on Line 17 and the amount which is excluded from the contingency provisions shown in Section C, Line 26g, Column (2). Multiply the computed amount by the percentage factor allowed by the grantor agency in accordance with the Federal program guidance. For those grants which provide for a fixed dollar allowance in lieu of a percentage allowance, enter the dollar amount of this allowance. Line 19 - Show the total amount of Lines 16, 17, and 18. (This is the amount to which the matching share ratio pre scribed in program legislation is applied.) Line 20 - Show the amount of Federal funds requested exclusive of funds for rehabilitation purposes. Line 21 - Enter the estimated amounts needed for rehabilitation expense if rehabilitation grants to individuals are made for which grantees are reimbursed 100 percent by the Federal grantor agency in accordance with program legislation. If the grantee shares in part of this expense, show the total amount on Line 13 instead of on Line 21 and explain in Section E. Line 22 - Show the total amount of the Federal grant re quested. Line 23 - Show the amount from Section D, Line 27h. Line 24 - Show the amount from Section D, Line 28c. Line 25 - Self-explanatory. American LegalNet, Inc. www.FormsWorkflow.com DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION OMB NO. 2120-0569 SECTION C - EXCLUSIONS Ineligible for Participation (1) 26. Classification a. Excluded from Contingency Provision (2) $ $ $ $ b. c. d. e. f. g. Totals SECTION D - PROPOSED METHOD OF FINANCING NON-FEDERAL SHARE $ 27. Grantee Share a. Securities b. Mortgages c. Appropriations (By Applicant) d. Bonds e. Tax Levies f. Non Cash g. Other (Explain) h. Total – Grantee Share 28. Other Shares a. State b. Other c. Total Other Shares $ 29. TOTAL SECTION E - REMARKS PART IV - PROGRAM NARRATIVE (ATTACH – SEE INSTRUCTIONS) FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73) PAGE 5 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS PART III SECTION C. EXCLUSIONS Line 26 a-g - Identify and list those costs in Column (1) which are part of the project cost but are not subject to Federal participation because of program legislation or Federal grantor agency instructions. The total amount on Line g should agree with the amount shown on Line 17 of Section B. Show in Column (2) those project costs that are subject to Federal participation but are not eligible for inclusion in the amount used to compute contingency amounts as provided in the Federal grantor agency instructions. SECTION D. PROPOSED METHOD OF FINANCING NON-FEDERAL SHARE Line 27 a-g - Show the source of the grantee’s share. If cash is not immediately available, specify the actions completed to date and those actions remaining to make cash available under Section E Remarks. Indicate also the period of time that will be required after execution of the grant agreement to obtain the funds. If there is a noncash contribution, explain what this contribution will consist of. state agency. If there is a noncash contribution, explain what the contribution will consist of under Section E Re-marks. Line 28b - Show the amount that will be contributed from other sources. If there is a noncash contribution, explain what the contribution will consist of under Section E Remarks. Line 27h - Show the total of Lines 27 a-g. This amount must equal the amount shown in Section B, Line 23. Line 28c - Show the total of Lines 28a and 28b. This amount must be the same as the amount shown in Section B, Line 24. Line 28a - Show the amount that will be contributed by a State or state agency, only if the applicant is not a State or Line 29 - Enter the totals of Line 27h and 28c. SECTION E. OTHER REMARKS Make any remarks pertinent to the project and provide any other information required by these instructions or the grantor agency. Attach additional sheets, if necessary. American LegalNet, Inc. www.FormsWorkflow.com PART IV PROGRAM NARRATIVE (Suggested Format) DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION OMB NO. 2120-0569 PROJECT: AIRPORT: 1. Objective: 2. Benefits Anticipated: 3. Approach: (See approved Scope of Work in final Application) 4. Geographic Location: 5. If Applicable, Provide Additional Information: 6: Sponsor’s Representative: (incl. address & tel. no.) FAA Form 5100-100 (9-03) SUPERSEDES FAA FORM 5100-100 (6-73) PAGE 6 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS PART IV PROGRAM NARRATIVE Prepare the program narrative statement in accordance with the following instructions for all new grant programs. Requests for supplemental assistance should be responsive to Item 5b only. Requests for continuation or refunding or other changes of an approved project should be responsive to Item 5c only. 1. OBJECTIVES AND NEED FOR THIS ASSISTANCE. Pinpoint any relevant physical, economic, social, financial, institutional, or other problems requiring a solution. Demonstrate the need for assistance and state the principal and subordinate objectives of the project. Supporting documentation or other testimonies from concerned interests other than the applicant may be used. Any relevant data based on planning studies should be included or footnoted. 2. RESULTS OR BENEFITS EXPECTED. Identify results and benefits to be derived. For example, include a description of who will occupy the facility and show how the facility will be used. For land acquisition or development projects, explain how the project will benefit the public. 3. APPROACH a. Outline a plan of action pertaining to the scope and detail of how the proposed work will be accomplished for each grant program. Cite factors which might accelerate or decelerate the work, and your reason for taking this approach as opposed to others. Describe any unusual features of the project such as design or technological innovations, reductions in cost or time, or extraordinary social and community involvements. b. Provide each grant program monthly or quarterly quantitative projections of the accomplishments to be achieved, if possible. When accomplishments cannot be quantified, list the activities in chronological order to show the schedule of accomplishments and their target dates. d. List each organization, cooperator, consultant, or other key individuals who will work on the project along with a short description of the nature of their effort or contribution. 4. GEOGRAPHIC LOCATION. Give a precise location of the project and area to be served by the proposed project. Maps or other graphic aids may be attached. 5. IF APPLICABLE, PROVIDE THE FOLLOWING INFORMATION: a. Describe the relationship between this project and other work planned, anticipated, or underway under the Federal Assistance listed under Part II, Section A, Item 10. b. Explain the reason for all requests for supplemental assistance and justify the need for additional funding. c. Discuss accomplishments to date and list in chronological order a schedule of accomplishments, progress, or milestones anticipated with the new funding re-quest. If there have been significant changes in the project objectives, location, approach or time delays, explain and justify. For other requests for changes or amendments, explain the reason for the change(s). If the scope or objectives have changed or an extension of time is necessary, explain the circumstances and justify. If the total budget has been exceeded or if individual budget items have changed more than the prescribed limits contained in Attachment K, Office of Management and Budget Circular No. A-102, explain and justify the change and its effect on the project. c. Identify the kinds of data to be collected and maintained, and discuss the criteria to be used to evaluate the results and success of the project. Explain the methodology that will be used to determine if the needs identified and discussed are being met and if the results and benefits identified in Item 2 are being achieved. American LegalNet, Inc. www.FormsWorkflow.com