Federal Aviation Administration (FAA) - 20220503-9081FAA Form 5100-110 (8/20) SUPERSEDES PREVIOUS EDITION Page 1
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 6/30/2023
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 Amount
Total N/A
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 (date) or when the availability of
apportioned funds lapses under 49 USC § 47117(b).
For the United States of America, Federal Aviation Administration:
Signature:
Name:
Title:
Date:
FAA Form 5100-110 (8/20) SUPERSEDES PREVIOUS EDITION Page 2
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 (City, State),
this day of ,
Signature of Sponsor’s Attorney: ________________________________________________________