4534 Statement Of Charter Operator, Direct Air Carrier

OMB No. 2106-0005
Expires 09/30/2012

Paperwork Reduction Act 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 2106-0005. Public reporting for this collection of
information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, completing and reviewing the
collection of information. All responses to this collection of information are voluntary. 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, U.S. Department
of Transportation, Office of International Aviation, X-46, 1200 New Jersey Avenue SE, Suite W-86-445, Washington, DC 20590.

STATEMENT OF CHARTER OPERATOR, DIRECT AIR CARRIER
AND DEPOSITORY BANK
INSTRUCTIONS: Date of filing for purposes of DOT regulations is the date properly completed forms are received
by DOT.

U.S. Department of
Transportation
Office of the Secretary
of Transportation

We _________________________________________________, ____________________________________________________
(Charter Operator)*

(Direct Air Carrier)

and ______________________________________________________________, certify that we have entered into a depository agreement on
(Depository Bank)

_________________________. This agreement covers proposed flight schedule number _____________________ a copy of which has been
(Date)

(Flight Schedule Number)

received by _______________________________________________________. This agreement complies with (§380.34) (§380.34a) of DOT’s
(Depository Bank)

Regulations (14 CFR §380.34 or §380.34a). The depository bank is insured by the Federal Deposit Insurance Corporation.
As signatories to this agreement, we fully understand, and will completely fulfill our respective obligations outlined in the agreement and
the above-stated DOT regulations.

CHARTER OPERATOR

DIRECT AIR CARRIER

BY: __________________________________________________

BY: _________________________________________________

(Signature)*

(Signature)*

_________________________________________________

________________________________________________

(Name in print)

(Name in print)

_________________________________________________

________________________________________________

(Title)

(Title)

______________________/ __________________________
(Phone Number)

_______________________/ ________________________

(Fax Number)

(Phone Number)

_________________________________________________

(Fax Number)

________________________________________________

(Street, Box Number)

(Street, Box Number)

_________________________________________________

________________________________________________

(City, State, Zip Code)

(City, State, Zip Code)

_________________________________________________

________________________________________________

(Date)**

(Date)**

DEPOSITORY BANK
BY: ________________________________________________
(Signature)*

_________________________________________________
(Name in print)

_________________________________________________
(Title)

_________________________/_______________________
(Phone Number)

(Fax Number)

_________________________________________________
(Street, Box Number)

_________________________________________________
(City, State, Zip Code)

_________________________________________________
(Date)**
**This document is not acceptable if not dated.

OST Form 4534

*Write “N.A.” if there is no charter operator
OST 4530, 32-35 Form Disk