Fillable Faa Form 5500-1 - Passenger Facility Charge (Pfc) Application printable pdf download

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OMB Approved 2120-0557

Exp. 8/31/2013

Federal Aviation

Administration

PASSENGER FACILITY CHARGE (PFC) APPLICATION

U. S. Department of Transportation

1. Application Type (Check all that apply)

FAA USE ONLY

a. Impose PFC Charges

Date Received

PFC Number

b. Use PFC Revenue

c. Amend PFC No. ____________________

_________________________

________________________

PART I

2. Public Agency Name, Address, and Contact Person

3. Airport(s) to Use

4. Consultation Dates

a. Date of Written Notice to Air Carriers:

Agency Name

________________________

b. Date of Consultation Meeting with Air

Address

________________________

Carriers:

City, State, ZIP ________________________

c. Date of Public Notice

Contact Person ________________________

PART II

5. Charges

a. Airport to Impose

b. Level

c. Total Estimated PFC

d. Proposed Effective

e. Estimated Expiration

Revenue by Level

Date:

Impose

$1.00

$2.00

$3.00

Use

Impose

$4.00

$4.50

Use

PART III

6. Attachments (Check all that Apply)

Attached

Submitted with Application Number

Document

________________________________

Airport Capital Improvement Plan

________________________________

Project Information (Attachment B)

________________________________

Air Carrier Consultation and Public Notice Information

________________________________

Request to Exclude Class(es) of Carriers

________________________________

Alternative Uses/Projects

________________________________

Competition Plan/Update

________________________________

ALP/Airspace/Environmental

________________________________

Notice of Intent Project Information

________________________________

PART IV

7. With respect to this PFC application I hereby certify as follows:

To the best of my knowledge and belief, all data in this application are true and correct;

This application has been duly authorized by the governing body of the public agency;

The public agency will comply with the assurances (Appendix A to Part 158) if the application is approved;

For those projects for which approval to use PFC revenue is requested, all applicable ALP approvals, airspace determinations, and

environmental reviews required by the National Environmental Policy Act have been completed.

If required, the public agency has submitted a competition plan in accordance with 49 U.S.C. 47106(f); and

If required by 49 U.S.C. 40117(d)(4), adequate provision for financing the airside needs, including runways, taxiways, aprons, and gates, has

been made by the public agency.

a. Typed Name of Authorized Representative

b. Title

c. Telephone Number

d. E-mail Address

e. Fax Number

f. Signature of Authorized Representative

g. Date Signed

Paperwork Reduction Act Statement: This form is the FAA's primary source for collecting information for the authority to collect PFC revenue for airport development.

This information is used to determine the eligibility and justification of airport development projects regarding safety, security, or capacity of the national air transportation

system; or which reduce noise or mitigate noise impacts resulting from an airport; or furnish opportunities for enhanced competition between or among air carriers. It is

estimated that it will take approximately 5-80 hours to fill out the application depending on the complexity. The use of the form is required to obtain FAA approval of

authority to collect PFC revenue (49 U.S.C. 40117(c)). No assurance of confidentiality is necessary or provided. It should be noted that an agency may not conduct or

sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number

associated with this collection of information is 2120-0557. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed

to the FAA at: 800 Independence Ave. SW, Washington, DC, 20591, Attn: Information Collections Clearance Officer, AIO-20.

FAA Form 5500-1 (8-10) Supersedes Previous Edition