5500-1 Passenger Facility Charge (PFC) Application

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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 currently valid OMB Control Number. The OMB Control Number for
this information collection is 2120-0557. Public reporting for this collection of information is estimated to be approximately 5-80 hours per response depending on the complexity of the project(s),
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this
collection of information are required to obtain FAA approval of authority to collect PFC revenue (49 U.S.C. 40117(c)). Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

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

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

b. Title

c. Telephone Number

d. E-mail Address

e. Fax Number

f. Signature of Authorized Representative

FAA Form 5500-1 (3-07) Supersedes Previous Edition

g. Date Signed