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PART 241 Form 41 Form A Certification

PDF

OMB NO: 2138-0013

EXPIRATION DATE: 08/31/2018

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 current valid OMB Control Number. The OMB Control Number for this information collection is 2138-0013. Public reporting for Schedule A, Certification is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are mandatory, as authorized by 14 CFR, Part 241. 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, Jeff Gorham, OAI/BTS, RTS-42, Room E34, 1200 New Jersey Avenue, SE, Washington, D.C. 20590 or e-mail – jeff.gorham@dot.gov.

REQUIREMENTS

RECORD DESCRIPTION/INSTRUCTIONS: Form A Certification

A certification statement is required identifying an appropriate official of the reporting carrier. The certification statement will read:

Period ended:

I, (Name) and (Title), of (Carrier Name), do certify that all schedules and supporting documents which are submitted herewith or have been submitted heretofore as parts of this report filed for the indicated period, have been prepared under my direction; that I have carefully examined them and declare that they correctly reflect the accounts and records of the company, and to the best of my knowledge and belief are a complete and accurate statement, after adjustments to reflect full accruals, of the operating revenues and expenses, income items, assets, liabilities, capital, retained earnings, and operating statistics for the periods reported in the financial schedules, the Schedule T-100 Traffic, and if applicable, the Passenger Origin-Destination Survey; that the various items herein reported were determined in accordance with the Code of Federal Regulations for Large Certificated Air Carriers as prescribed by the Department of Transportation; and that the data contained herein are reported on a basis consistent with that of the preceding report except as specifically noted in the financial and statistical statements.

Date:

Signature:

Name (Please Print or Type):

Title 18 U.S.C. Sec. 1001, Crimes and Criminal Procedures, makes it a criminal offense subject-to a maximum fine of $10,000 or imprisonment for not more than 5 years, or both, to knowingly and willfully make or cause to be made any false or fraudulent statements or representation in any matter within jurisdiction of any agency of the United States.

The Confidential Information Protection and Statistical Efficiency Act 2002 (44 USC 3501), requires a statistical agency to clearly identify information it collects for non-statistical purposes. BTS hereby notifies the respondents and the public that BTS uses the information it collects under this OMB approval for non-statistical purposes including, publication of both respondent’s identity and it’s data, submission of the information to agencies outside BTS for review, analysis and possible use in regulatory and other administrative matters.

Per quarter, it can take each air carrier between 30 and 300 hours to complete the required financial reports and between 6 and 18 hours to complete the required T-100 monthly traffic reports.

RECORD FORMAT:

Once signed, the Form A Certification must be published as an electronic “portable document format” file format, for uploading to the eSubmit application.

The portable document format file MUST BE indicated when naming the file, by using the letters [PDF] or [pdf] following the file name, as the file name extension. You must have Adobe software downloaded on your computer in order to “save as/print” your document as a ‘pdf’ file.

While the file name is flexible and may be determined by the individual air carrier, the portable document format (pdf) file format is required, as outlined in the rule entitled, Submitting Airline Data via the Internet.

Suggested file name: XX201003- F41-A-Cert.pdf