Form TSA-FORM 2502 TSA-FORM 2502 PASSENGER CIVIL AVIATION SECURITY SERVICE FEES – QUARTER

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

PASSENGER CIVIL AVIATION SECURITY SERVICE FEES – QUARTERLY REPORT

INSTRUCTIONS: This form must be completed on a quarterly basis by designated individuals for air carriers and foreign air carriers that sell air transportation on flights originating from an airport within the U.S.  in accordance with 49 C.F.R. Part 1510.  The air carrier must report on monthly fees that are imposed, collected, refunded, and remitted to TSA.  Forms shall be completed online for those who have access to the September 11th Security Fee Quarterly Reports site. For those who do not have access to this site, completed forms must be faxed to the Office of Revenue, Compliance Branch at (571) 227-2904.
SECTION I. Submitter Information
Name (last, first, MI)      				Phone No.      
Title      
Address: (street, city, state, zip)      
SECTION II. Airline Information
Carrier Name      				Carrier Code      
SECTION III. Reporting Period
Year 20__	Quarter (select one) 1st 2nd 3rd 4th
SECTION IV. Monthly Transportation Security Fees
Month/Year		20     	20     		20     
Monthly security fees Imposed on passengers:		$      	$      		$      
Monthly security fees Collected from passengers:		$      	$      		$      
Monthly security fees Refunded to passengers:		$      	$      		$      
Monthly security fees Remitted to the TSA:		$      	$      		$      

Imposed: Actual total amount of these fees charged to the passengers at the time air transportation is sold.

Collected: Actual total amount of these fees collected from passengers.

Refunded: Fees refunded to passengers as a result of a change in reservation, over-collection, cancellation, etc.

Remitted: Total fees paid to TSA.

Signature		Date

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: This collection of information is mandatory pursuant to the Aviation and Transportation Security Act, Pub. L. 107-72, November 19, 2001, as amended, and 49 C.F.R. Part 1510, and will be used to ensure that air carriers are in compliance with the requirements to collect and remit the September 11th Security Fee. It is estimated that the time to complete this form is approximately 1 hour. Please note 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 for this collection is 1652-0001, which expires 08/31/2015.

Previous editions of this form are obsolete.

TSA Form 2502 (05/14) rev. [File: 2500.1] Page 1 of 2

OMB Control No. 1652-0001, which expires 08/31/2015