LEO Reimbursement Request

OMB No. 1652-XXXX Exp. Date XX/XX/XX

INSTRUCTIONS: LEO Reimbursement requests much be made to the Law Enforcement Officer Reimbursement Program (LRP) for each period of performance for which reimbursement is sought. Completed requests must be signed by the local TSA Federal Security Director (FSD) and forwarded to the LRP by fax at (703) 603-3010, email at lrp-efax-central@tsa.dhs.gov, lrp-efax-east@tsa.dhs.gov or, lrp-efax-west@tsa.dhs.gov. Additionally, completed requests may be mailed to TSA Headquarters in Arlington, VA. PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: Providing this information is voluntary. However, response is required to obtain benefits. It will take no more than one hour to complete this form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The control number assigned to this collection is OMB 1652-XXXX, which expires on XX/XX/XX.

SECTION I. Invoice Information

Agreement No.       Middle Name:       Last Name:      

Invoice Date     

Airport Name      

Airport Code      

DUNS No.      

TINS No.      

Invoice No. (each invoice number must be unique)      

Office Address      

E-mail Address      

Phone No.      

Close-out Final Invoice

SECTION II. Invoicing Point of Contact

Name      

Address      

E-mail Address      

Phone No.      

Fax No.      

SECTION III. Service Information

Period of Performance      to     

Description of Services Provided      

Total Amount of LEO Hours Billed      

Hourly Rate (actual hourly rate or not to exceed rate per agreement, whichever is less) $     

Total Reimbursement Request $     

Actual Cost of LEO Coverage $     

SECTION IV. Banking Information

Checking Savings Change of Account

Routing No.      

Account No.      

Ensure all information in your Contractor Central Registry Account (CCR) is up to date by accessing www.ccr.gov or www.bpn.gov/ccr/default.aspx; To inquire about invoice payment status, access the Federal Payment Center's Website (https://www.fincen.uscg.mil/secure/payment.htm) or call (866) 606-8220 or (757) 523-6920; and, When searching for invoice payments use all caps and no special characters.

SECTION V. Invoicing Point of Contact Certification

I certify that the information provided is truthfully and accurately based on actual hours performed in support of TSA Security Checkpoints in accordance with 49 U.S.C. §§ 106(m) and114(m). All information provided pertains to the law enforcement coverage provided to the above mentioned airport which follows all rules, regulations, and guidelines pursuant to the LEO Agreement in accordance with 49 U.S.C. §§ 114(g), 44901(g), 44903(e) and 44922(f).

     

     

     

Name

Signature

Date

Contact No.

Section VI. FSD and/or Designee Authorization

Name      

Title      

Phone No.      

     

Signature

Date

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

LEO Reimbursement Request

TSA Form 35XX (MM/DD) rev. [File: XXXX]