Free PASSENGER FACILITY CHARGE (PFC) APPLICATION - Federal

Print Form
OMB Approved 2120-0557 Exp. 3/31/2010
Federal Aviation Administration
U. S. Department of Transportation

PASSENGER FACILITY CHARGE (PFC) APPLICATION
FAA USE ONLY

1. Application Type (Check all that apply) a. Impose PFC Charges b. Use PFC Revenue c. Amend PFC No. ____________________ Date Received

PFC Number ________________________

_________________________

PART I
2. Public Agency Name, Address, and Contact Person Agency Name Address ________________________ ________________________ 3. Airport(s) to Use 4. Consultation Dates a. Date of Written Notice to Air Carriers: b. Date of Consultation Meeting with Air Carriers: c. Date of Public Notice

City, State, ZIP ________________________ Contact Person ________________________

PART II
5. Charges a. Airport to Impose b. Level $1.00 $4.00 $2.00 $4.50 $3.00 c. Total Estimated PFC Revenue by Level Impose Use Impose Use d. Proposed Effective Date: e. Estimated Expiration Date:

PART III
6. Attachments (Check all that Apply) Attached Submitted with Application Number a. ________________________________ b. ________________________________ c. ________________________________ d. ________________________________ e. ________________________________ f. ________________________________ g. ________________________________ ________________________________ h. i. ________________________________ 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 d. E-mail Address f. Signature of Authorized Representative c. Telephone Number e. Fax Number 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 (3-07) Supersedes Previous Edition