4533 Statement Of Charter Operator

OMB No. 2106-0005
Expires 03/31/2016

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 Control Number for this information collection is. 21060005. 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 OR
DIRECT AIR CARRIER, AND SECURER
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 or Director Air Carrier)

and _______________________________________________________________________________________________________________
(Securer)

certify that we have entered into a security agreement number _________________________________________________________, in the
(Security Agreement Number)

amount of $_____________________________ on _______________________________. This agreement covers proposed flight schedule
(Amount)

(Date)

number __________________________, a copy of which has been received by ___________________________________________________.
(Securer)

This agreement complies with (§380.34) (§380.34a) of DOT’s Regulations (14 CFR §380.34 or §380.34a).
This agreement is a (Check one):
Surety Bond
Surety Trust Agreement
Letter of Credit (for participants of flight schedule number ____________________________________)
Check one of the following:
This agreement is in an unlimited amount.
There are no outstanding claims against this agreement.
There are outstanding claims against this agreement in the amount of $_________________. We have executed a rider to the agreement
on ____________________, increasing the coverage by this amount.*
(Date)

*In place of this sentence, the following statement may be used: “___________________________________________________ will separately pay any claims for
(Securer)

which it may be liable without impairing the security agreement or reducing the amount of coverage.”

CHARTER OPERATOR or DIRECT AIR CARRIER
BY:

___________________________________________

SECURER
BY:

______________________________________________

(Signature)*

(Signature)

___________________________________________

______________________________________________

(Name in print)

(Name in print)

___________________________________________

_______________________________________________

(Title)

(Title)

_____________________/_____________________
(Phone Number)

(Fax Number)

___________________________________________
(Street, Box Number)

___________________________________________
(City, State, Zip Code)

___________________________________________
(Date)**

_______________________/________________________
(Phone Number)

(Fax Number)

_______________________________________________
(Street, Box Number)

_______________________________________________
(City, State, Zip Code)

_______________________________________________
(Date)**

**This document is not acceptable if not dated.

OST Form 4533

OST 4530, 32-35 Form Disk