5100-139 LOI Application Financial Template

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Overview

PRA Statement
Program-Level Data Entry
Alternative Disbursement Sched
Project-Level Data Entry
Summary Analytical Sheet

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Sheet 1: PRA Statement

FAA Form 5100-139, Letter of Intent (LOI) Application Financial Template

Paperwork Reduction Act 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 the Federal Aviation Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110.

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Sheet 2: Program-Level Data Entry

LOI Application Financial Template																					Order 5100.38C
Sponsors requesting Letters of Intent (LOIs) are required to submit the information shown, in substantially the same format as this template. Sponsors are strongly encouraged to use this template, as it may help to expedite the review and approval process. Regardless, Sponsors should review the instructions contained in Chapter 6 of Order 5100.38Dcarefully, because those instructions contain specific parameters for what to include on certain key lines of this template.
Airport Sponsor Information
1	[insert airport name]
2	[insert three-letter identifier]
3	[insert city and state]
4	[insert hub category - Large, Medium, Small or Nonhub]
5	[insert airport owner/operator -- e.g., "City of East Rutherford"]
6	[insert submission date]
Capital Costs and Annual Cashflow Requirements - Proposed Action
				Totals	as %		Prior Years	FFY-2015	FFY-2016	FFY-2017	FFY-2018	FFY-2019	FFY-2020	FFY-2021	FFY-2022	FFY-2023	FFY-2024	FFY-2025	FFY-2026	FFY-2027	FFY-2028
7	Professional Services			$0	n/a
8	Land Acquisition			0	n/a
9	Runway	[insert runway designation]		0	n/a
10	Runway	[insert runway designation]		0	n/a
11	Runway	[insert runway designation]		0	n/a
12	Runway	[insert runway designation]		0	n/a
13	Other Airside			0	n/a
14	Terminal			0	n/a
15	Landside			0	n/a
16	Infrastructure			0	n/a
	Summary			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Cumulative Needs						$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Capital Funding Sources - Proposed Action
				Totals	as %		Prior Years	FFY-2015	FFY-2016	FFY-2017	FFY-2018	FFY-2019	FFY-2020	FFY-2021	FFY-2022	FFY-2023	FFY-2024	FFY-2025	FFY-2026	FFY-2027	FFY-2028
	Federal and State Grants
17	Entitlements - Grants Awarded			$0	n/a
18	Entitlements - Future Grants			0	n/a
19	Discretionary - LOI Request			0	n/a
20	Discretionary - Other - Awarded			0	n/a
21	Discretionary - Other - Future Grants			0	n/a
22	Discretionary - Noise - Awarded			0	n/a
23	Discretionary - Noise - Future Grants			0	n/a
24	State Apportionment - Grants Awarded			0	n/a
25	State Apportionment - Future Grants			0	n/a
26	Other Federal (non-AIP) - Grants Awarded			0	n/a
27	Other Federal (non-AIP) - Future Grants			0	n/a
28	State - Grants Awarded			0	n/a
29	State - Future Grants			0	n/a
	Subtotal - Federal/State Grants			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Passenger Facility Charges
30	PFCs - $3.00 Application Approved			$0	n/a
31	PFCs - $3.00 Application Submitted			0	n/a
32	PFCs - $3.00 Future Application(s)			0	n/a
33	PFCs - $4.50 Application Approved			0	n/a
34	PFCs - $4.50 Application Submitted			0	n/a
35	PFCs - $4.50 Future Application(s)			0	n/a
36	PFCs - Future Level		[assumed level]	0	n/a
	Subtotal - PFCs			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Debt
37	Revenue Bonds - MII Approved			$0	n/a
38	Revenue Bonds - MII pending			0	n/a
39	General Obligation - Authority in Place			0	n/a
40	General Obligation - Authority Pending			0	n/a
41	Other Debt - Authority in Place			0	n/a
42	Other Debt - Authority Pending			0	n/a
	Subtotal - Debt			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
43	Airport Funds			$0	n/a
44	Tenant or Third-Party Funds			$0	n/a
					n/a
	Total - All Funding Sources			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Cumulative Sources						$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Unmet Funding Needs				Totals			Prior Years	2015	2016	2017	2018	2019	2020	2021	2022	2023	2024	2025	2026	2027	2028
				$0			$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
			Summary Funding Sources
			Discretionary - LOI Request	$0
			Other AIP funds	$0
			Other Federal funding	$0
			State grants	0
			PFCs	$0
			Bonds	$0
			Other	$0
			Total	$0
			Funding Status
			Discretionary - LOI Request	$0
			Grants awarded	$0
			Approved PFCs	$0
			Approved bonds	$0
			Future grants	$0
			Future PFCs	$0
			Future bonds	$0
			Other	$0
			Total	$0
Capital Costs and Annual Cashflow Requirements - Other Capital Plans
				Totals	as %		Prior Years	FFY-2015	FFY-2016	FFY-2017	FFY-2018	FFY-2019	FFY-2020	FFY-2021	FFY-2022	FFY-2023	FFY-2024	FFY-2025	FFY-2026	FFY-2027	FFY-2028
45	Professional Services			$0	n/a
46	Land Acquisition			0	n/a
47	Runways			0	n/a
48	Other Airside			0	n/a
49	Terminal			0	n/a
50	Landside			0	n/a
51	Infrastructure			0	n/a
	Summary			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Cumulative Needs						$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Capital Funding Sources - Other Capital Plans					n/a
					n/a
				Totals	as %		Prior Years	FFY-2015	FFY-2016	FFY-2017	FFY-2018	FFY-2019	FFY-2020	FFY-2021	FFY-2022	FFY-2023	FFY-2024	FFY-2025	FFY-2026	FFY-2027	FFY-2028
	Federal and State Grants
52	Entitlements - Grants Awarded			$0	n/a
53	Entitlements - Future Grants			0	n/a
54	Discretionary - LOI Request			0	n/a
55	Discretionary - Other - Awarded			0	n/a
56	Discretionary - Other - Future Grants			0	n/a
57	Discretionary - Noise - Awarded			0	n/a
58	Discretionary - Noise - Future Grants			0	n/a
59	State Apportionment - Grants Awarded			0	n/a
60	State Apportionment - Future Grants			0	n/a
61	Other Federal (non-AIP) - Grants Awarded			0	n/a
62	Other Federal (non-AIP) - Future Grants			0	n/a
63	State - Grants Awarded			0	n/a
64	State - Future Grants			0	n/a
	Subtotal - Federal/State Grants			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
					n/a
	Passenger Facility Charges				n/a
65	PFCs - $3.00 Application Approved			$0	n/a
66	PFCs - $3.00 Application Submitted			0	n/a
67	PFCs - $3.00 Future Application(s)			0	n/a
68	PFCs - $4.50 Application Approved			0	n/a
69	PFCs - $4.50 Application Submitted			0	n/a
70	PFCs - $4.50 Future Application(s)			0	n/a
71	PFCs - Future Level		[assumed level]	0	n/a
	Subtotal - PFCs			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Debt
72	Revenue Bonds - MII Approved			$0	n/a
73	Revenue Bonds - MII pending			0	n/a
74	General Obligation - Authority in Place			0	n/a
75	General Obligation - Authority Pending			0	n/a
76	Other Debt - Authority in Place			0	n/a
77	Other Debt - Authority Pending			0	n/a
	Subtotal - Debt			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
78	Airport Funds			$0	n/a
79	Tenant or Third-Party Funds			0	n/a
	Total - All Funding Sources			$0	n/a		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Cumulative Sources						$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Unmet Funding Needs				Totals			Prior Years	2015	2016	2017	2018	2019	2020	2021	2022	2023	2024	2025	2026	2027	2028
				$0			$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
			Summary Funding Sources
			Discretionary - LOI Request	$0
			Other AIP funds	$0
			Other Federal funding	$0
			State grants	0
			PFCs	$0
			Bonds	$0
			Other	$0
			Total	$0
			Funding Status
			Discretionary - LOI Request	$0
			Grants awarded	$0
			Approved PFCs	$0
			Approved bonds	$0
			Future grants	$0
			Future PFCs	$0
			Future bonds	$0
			Other	$0
			Total	$0
Capital Costs and Annual Cashflow Requirements - Other Capital Plans
				Totals	as %		Prior Years	FFY-2015	FFY-2016	FFY-2017	FFY-2018	FFY-2019	FFY-2020	FFY-2021	FFY-2022	FFY-2023	FFY-2024	FFY-2025	FFY-2026	FFY-2027	FFY-2028
	Professional Services			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Land Acquisition			0	#DIV/0!		0	0	0	$0	0	0	0	0	0	0	0	0	0	0	0
	Runways			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Other Airside			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Terminal			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Landside			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Infrastructure			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Summary			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Cumulative Needs						$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Capital Funding Sources - Other Capital Plans
				Totals	as %		Prior Years	FFY-2015	FFY-2016	FFY-2017	FFY-2018	FFY-2019	FFY-2020	FFY-2021	FFY-2022	FFY-2023	FFY-2024	FFY-2025	FFY-2026	FFY-2027	FFY-2028
	Federal and State Grants
	Entitlements - Grants Awarded			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Entitlements - Future Grants			0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Discretionary - LOI Request			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Discretionary - Other - Awarded			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Discretionary - Other - Future Grants			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Discretionary - Noise - Awarded			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Discretionary - Noise - Future Grants			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	State Apportionment - Grants Awarded			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	State Apportionment - Future Grants			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Other Federal (non-AIP) - Grants Awarded			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Other Federal (non-AIP) - Future Grants			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	State - Grants Awarded			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	State - Future Grants			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Subtotal - Federal/State Grants			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Passenger Facility Charges
	PFCs - $3.00 Application Approved			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	PFCs - $3.00 Application Submitted			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	PFCs - $3.00 Future Application(s)			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	PFCs - $4.50 Application Approved			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	PFCs - $4.50 Application Submitted			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	PFCs - $4.50 Future Application(s)			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	PFCs - Future Level		[assumed level]	0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Subtotal - PFCs			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Debt
	Revenue Bonds - MII Approved			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Revenue Bonds - MII pending			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	General Obligation - Authority in Place			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	General Obligation - Authority Pending			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Other Debt - Authority in Place			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Other Debt - Authority Pending			0	#DIV/0!		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	Subtotal - Debt			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Airport Funds			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Tenant or Third-Party Funds			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Total - All Funding Sources			$0	#DIV/0!		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	Cumulative Sources						$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Unmet Funding Needs				Totals			Prior Years	2015	2016	2017	2018	2019	2020	2021	2022	2023	2024	2025	2026	2027	2028
				$0			$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
			Summary Funding Sources
			Discretionary - LOI Request	$0
			Other AIP funds	$0
			Other Federal funding	$0
			State grants	0
			PFCs	$0
			Bonds	$0
			Other	$0
			Total	$0
			Funding Status
			Discretionary - LOI Request	$0
			Grants awarded	$0
			Approved PFCs	$0
			Approved bonds	$0
			Future grants	$0
			Future PFCs	$0
			Future bonds	$0
			Other	$0
			Total	$0

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Sheet 3: Alternative Disbursement Sched

LOI Application Financial Template
Data Entry Sheet #2
Airport Sponsor Information
[insert airport name]
[insert three-letter identifier]
[insert city and state]
[insert hub category - Large, Medium, Small or Nonhub]
[insert airport owner/operator -- e.g., "City of East Rutherford"]
[insert submission date]
Alternative Disbursement Proposal(s)
OFFICIAL REQUEST	Totals		2015	2016	2017	2018	2019	2020	2021	2022	2023	2024	2025	2026	2027	2028
Discretionary - LOI disbursement schedule	$0		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
ALTERNATIVE A
Discretionary - LOI disbursement schedule	$0
Change (if any) in LOI Discretionary funding	0
Impact on costs and/or other funding sources			[insert explanation]
ALTERNATIVE B
Discretionary - LOI disbursement schedule	$0
Change (if any) in LOI Discretionary funding	0
Impact on costs and/or other funding sources			[insert explanation]
ALTERNATIVE C
Discretionary - LOI disbursement schedule	$0
Change (if any) in LOI Discretionary funding	0
Impact on costs and/or other funding sources			[insert explanation]
ALTERNATIVE D
Discretionary - LOI disbursement schedule	$0
Change (if any) in LOI Discretionary funding	0
Impact on costs and/or other funding sources			[insert explanation]

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Sheet 4: Project-Level Data Entry

LOI Application Financial Template
Data Entry Sheet #3
Airport Sponsor Information
[insert airport name]
[insert three-letter identifier]
[insert city and state]
[insert hub category - Large, Medium, Small or Nonhub]
[insert airport owner/operator -- e.g., "City of East Rutherford"]
[insert submission date]
Individual Project Components
			Part of Proposed Action?		Include in BCA?			LOI Project	Proposed Action	Overall Capital Plan		Professional Services	Land Acquisition	Runways	Other Airside	Terminal	Landside	Infrastructure
	Cost		Y/N		Y/N	Justification for Requested Exclusion
Example: Taxiway F Rehabilitation	$1,800,000		N		N	Will occur with or without Night Vision Program		$0	$0	$1,800,000
Example: EIS - Night Vision Program	$4,600,000		Y		N	Costs incurred regardless of outcome, and already funded		$0	$4,600,000	$4,600,000
[insert project by project]								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
								$0	$0	$0
Summary	$0		$0		$0	$0		$0	$0	$0		$0	$0	$0	$0	$0	$0	$0

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Sheet 5: Summary Analytical Sheet

LOI Application Financial Template
Airport Sponsor Information
1	[insert airport name]
2	[insert three-letter identifier]
3	[insert city and state]
4	[insert hub category - Large, Medium, Small or Nonhub]
5	[insert airport owner/operator -- e.g., "City of East Rutherford"]
6	[insert submission date]
			Discretionary - LOI Request	$0
			Other AIP funds	$0
			Other Federal funding	$0
			State grants	0
			PFCs	$0
			Bonds	$0
			Other	$0
				$0
			Funding Status
			Discretionary - LOI Request	$0
			Grants awarded	$0
			Approved PFCs	$0
			Approved bonds	$0
			Future PFCs	$0
			Future bonds	$0
			Other	$0
			Total	$0
						Summary Cashflow Needs	$0
						0	0