Form 5500-1 Passenger Facility Charge (PFC) Application

Print Form
OMB Approved 2120-0557
Exp. 3/31/2010
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

b. Use PFC Revenue
c. Amend PFC No. ____________________

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:

City, State, ZIP ________________________

c. Date of Public Notice

Contact Person ________________________

PART II
5. Charges
a. Airport to Impose

b. Level
$1.00

$2.00

$4.00

$3.00

$4.50

c. Total Estimated PFC
Revenue by Level
Impose

d. Proposed Effective
Date:

e. Estimated Expiration
Date:

Use
Impose
Use

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

f. Signature of Authorized Representative

b. Title

c. Telephone Number

d. E-mail Address

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