Form 41, Schedule A - Report of Financial and Operating Statistics for Large Certificated Air Carriers

OMB No.: 2138-0013, Expiration Date: 10/31/2011

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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. This report is released to the public unless the respondent receives confidentiality. 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, Bernie Stankus, OAI/BTS/RITA, RTS-42, 1200 New Jersey Avenue, SE, D.C. 20590 or e-mail bernard.stankus@dot.gov.

Period ended ___________________________, 20 ____

______________________________________________
(Full name of reporting company)

CERTIFICATION *

I, the undersigned ________________________________
(Title of officer in charge of accounts)

of the _________________________________________
(Full name of reporting company)

do certify that this report and all schedules, ADP-media submissions, Passenger Origin-Destination Survey submissions and supporting documents which are submitted herewith or have been submitted heretofore as parts of this report filed for the above 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 several schedules, the Schedule T-100 ADP-media submissions, and the Passenger Origin-Destination Survey; that the various items herein reported were determined in accordance with the Uniform System of Accounts and Reports for Large Certificated Air Carriers 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.

_________________________________
(Signature)

_________________________________
(Air carrier post office address)

Dated _____________________, 20 ____

• Title 18 U.S.C. Sec. 1001, Crimes and Criminal Procedure, 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 representations in any mater 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 TS uses the information it collects under this OMB approval for non-statistical purposes including, publication of both respondents identity and its 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 1 and 12 hours to complete the required T-100 monthly traffic reports.

BTS Form 41 Schedule A