Q4 2021 Template - 4112 Only

QUESTIONS FOR THE BASIC PSP Q4 2021 TEMPLATE
Sections
Headcount & Compensation - Employee Headcount

Section Q1
Q2
Q3

#
#
#

Q4

#

Q5

Calc.

Q6

Text Box

Q7

#

Section Q1
Q2
Q3

#
#
#
#
#
#
#
#

Q9

Upload

Q10

#

Q11

Conditional Text Box (Only
required if #>0 entered in
Q10)

Q12

#

Q13

Conditional Text Box (Only
required if #>0 entered in
Q12)

Section -

Q3

Q4

Q5

Q6
Q7
Q8
Q9
Q10
Q11
Q12
Q13

Q2
Q3
Q4

Q5

Number of jobs created and/or retained DURING the Report Quarter.*
Total Employee Wages and Salaries.
Total Employee Benefits.
Total Employee Wages, Salaries & Benefits Paid.

ALL
ALL
ALL

Total Amount of PSP1 funds spent DURING the Report Quarter.
Total Amount of PSP1 funds spent on expenses other than Salary, Wages and Benefits DURING the Report Quarter.
Total Amount of PSP1 Top-Off funds spent DURING the Report Quarter.
Total Amount of PSP1 Top-Off funds spent on expenses other than Salary, Wages and Benefits DURING the Report Quarter.
Total Amount of PSP2 funds spent DURING the Report Quarter.
Total Amount of PSP2 funds spent on expenses other than Salary, Wages and Benefits DURING the Report Quarter.
Total Amount of PSP3 funds spent DURING the Report Quarter.
Total Amount of PSP3 funds spent on expenses other than Salary, Wages and Benefits DURING the Report Quarter.

PSP1
PSP1
PSP1
PSP1
PSP2
PSP2
PSP3
PSP3

If (a) Total Amount of PSP1, PSP2, PSP3 or a combination of funds spent is greater than Total Employee Wages, Salaries, and Benefits
or (b) Total Amount of PSP1, PSP2, PSP3 or a combination of funds spent on expenses other than Salary, Wages, and Benefits is
greater than zero, please upload an explanation which must include an itemized list of expenses by program.

ALL

Please enter the number of Employees whose Pay Rate was reduced, without their consent, DURING the Report Quarter.

PSP2 Contractors with unspent
PSP2 funds, PSP3 Recipients
with unspent PSP3 funds

If the number of such Employees is not zero, please upload an explanation.

PSP2 Contractors with unspent
PSP2 funds, PSP3 Recipients
with unspent PSP3 funds

Please enter the number of Employees whose Benefits were reduced, without their consent, DURING the Report Quarter.

PSP2 Contractors with unspent
PSP2 funds, PSP3 Recipients
with unspent PSP3 funds

If the number of such Employees is not zero, please upload an explanation.

PSP2 Contractors with unspent
PSP2 funds, PSP3 Recipients
with unspent PSP3 funds

Executive Compensation/Dividends
#

Enter the number of such Employees and Corporate Officers who received Severance Pay or Other Benefits DURING the Report Quarter
ALL
that exceeded twice their 2019 Total Compensation.

Conditional Upload (Only If the number of such Employees and Corporate Officers is not zero, please upload an explanation which includes a list of the
required if #>0 entered in Q1) Employee/Corporate Officer positions and their Total Severance/Other Benefits received.
#

ALL

Enter the total number of such Corporate Officers or Employees whose Total Compensation during any 12 consecutive months ending
DURING the Report Quarter exceeded their 2019 Total Compensation. Please note, this only applies to Corporate Officers or Employees ALL
whose Total Compensation in calendar year 2019 exceeded $425,000.

Conditional Upload (Only If the number of such Employees and Corporate Officers is not zero, please upload an explanation which includes a list of the
required if #>0 entered in Q3) Employee/Corporate Officer positions and their Total Compensation received.
Enter the number of such Corporate Officers and Employees whose Total Compensation during any 12 consecutive months ending
DURING the Report Quarter exceeded the sum of $3,000,000 and 50% of the excess over $3,000,000 of their Total Compensation
#
received in calendar year 2019. Please note, this only applies to Corporate Officers or Employees whose Total Compensation in calendar
year 2019 exceeded $3,000,000.
Conditional Upload (Only If the number of such Employees and Corporate Officers is not zero, please upload an explanation which includes a list of the
required if #>0 entered in Q5) Employee/Corporate Officer positions and their Total Compensation received.
Has the Recipient purchased an equity security of the Recipient/parent company listed on a national securities exchange DURING the
Y/N
Report Quarter?
Conditional Upload (Only If yes, please upload an explanation that includes the name of the company, the number of shares, the dollar amount, and the date of the
required if 'Y' entered in Q7) transaction.
Has the Recipient paid dividends, or made any other capital distributions, with respect to the Recipient's common stock (or equivalent
Y/N
equity interest) DURING the Report Quarter?
Conditional Upload (Only
If yes, please upload an explanation that includes the dollar amount and the date of the transaction.
required if 'Y' entered in Q9)
Conditional Y/N (Only
If yes, was the entity that paid a dividend or made a capital distribution an S Corp or pass-through entity?
required if 'Y' entered in Q9)
Conditional Y/N (Only
If yes, was the dividend or capital distribution to cover its owners’ tax obligations in respect of the entity’s earnings?
required if 'Y' entered in Q9)
Conditional Upload (Only
required if 'N' entered in Q11 If you answered 'no' to either of the last two questions, please upload an explanation.
or Q12)

Section Q1

If the total number of involuntary terminations or furloughs is not zero, please enter an explanation.

Headcount & Compensation - Additional Compensation

Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8

Q2

Total Number of Involuntary Terminations or Furloughs DURING the Report Quarter.
Changes in Employee Headcount.

ALL
ALL
ALL
PSP2 Contractors with unspent
PSP2 funds, PSP3 Recipients
with unspent PSP3 funds
ALL
PSP2 Contractors with unspent
PSP2 funds, PSP3 Recipients
with unspent PSP3 funds
ALL

Headcount & Compensation - Employee Wages, Salaries & Benefits
#
#
Calc.

Section -

Q1

Total Number of Employees at START of the Report Quarter.
Total Number of New Hires hired DURING the Report Quarter.
Total Number of Permitted Terminations or Furloughs DURING the Report Quarter.

4112 Category

ALL

ALL

ALL
PSP2, PSP3
PSP2, PSP3
PSP2, PSP3
PSP2, PSP3
PSP2, PSP3
PSP2, PSP3
PSP2, PSP3

Fundamental Changes
Y/N

Have you transferred, pledged, mortgaged, encumbered, or otherwise assigned this Agreement or any Payroll Support provided under this
Agreement, or any interest therein, or any claim, account receivable, or funds arising thereunder or accounts holding Payroll Support, to
ALL
any party, bank, trust company, or other person?

Conditional Y/N (Only
If yes, did you seek Treasury’s prior written approval for this action, as required under paragraph 43 of the PSP Agreement?
required if 'Y' entered in Q1)
Conditional Date Text Box
(Only required if 'Y' entered in If yes, please provide the date of Treasury's written approval.
Q2)
Have there been any changes in or transfers of ownership of the company since the execution of your PSP1, PSP2, or PSP3 Agreement,
Y/N
as applicable?
If you answered “Yes” to any of the questions listed above, you are required to upload supporting documentation, as applicable and in
sufficient detail, including, for example, a detailed explanation regarding the transaction (e.g., equity purchase or asset purchase), the
Conditional Upload (Only
date of the transaction, effected assets and liabilities, and other relevant information.
required if 'Y' entered in Q1,
Q2, or Q4)
If you answered “Yes” to the question about seeking Treasury’s prior written approval in accordance with paragraph 43 of the PSP
Agreement, please be sure to include a copy of the written approval.

ALL
ALL
ALL

ALL

QUESTIONS FOR THE BASIC PSP Q4 2021 TEMPLATE
Sections
Section -

4112 Category

Document Uploads

Q1

Upload

Q2
Q3
Q4
Q5
Q6
Q7

Check Box
#
#
Y/N
Y/N
Y/N

Q8

Upload

Q9
Q10
Q11
Q12
Q13
Q14
Q15

Text Box
Y/N
Y/N
Y/N
Y/N
Y/N
Text Box

Please Submit the Form 941 (or IRS-acceptable equivalent) submitted to the Internal Revenue Service for the Report Quarter in a PDF
format.
Check box if NOT required to submit IRS Form 941.
Number of Employees (Line 1).
Wages, Tips and Other Compensation (Line 2).
Business Closed (Line 17).
Seasonal (Line 18).
Do you file through EDGAR with the SEC?
Please provide the following financial information uploads for the Report Quarter: 1) income statement; 2) balance sheet; 3) statement of
cash flow; 4) notes to financial statement; and 5) name and address of auditor/reviewer of statements.
If any of the five required documents are not available for upload, please provide an explanation (enter "n/a" if not applicable).
Did you upload an Income Statement?
Did you upload a Balance Sheet?
Did you upload a Statement of Cashflow?
Did you upload Notes to Financial Statements?
Did you upload a Name and Address of Auditor/reviewer of the statements?
If you would like to provide explanations or greater detail to any of your responses above, please enter explanation here.

ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL