Form TSA Form 3503 TSA Form 3503 LEO Reimbursement Request-Invoice

OMB Control Number: 1652-0063

Expiration Date: 12/31/2018

DEPARTMENT OF HOMELAND SECURITY Transportation Security Administration LEO REIMBURSEMENT REQUEST INVOICE

INSTRUCTIONS: This form is to be submitted monthly by participants of the Law Enforcement Officer (LEO) Reimbursement Program (LRP). An invoice is required for each Period of Performance for which payment is sought. All submissions must be accompanied by supporting documentation demonstrating actual cost/outlay for services provided (e.g. payroll report, ledger, etc.). The completion of Section VI and/or the submission of checkpoint logs, timesheets, etc. are not a substitute for documentation of actual cost. Completion of all fields is required. LEO Reimbursement Program Invoices must be submitted to the local TSA Federal Security Director (FSD) for signature. FSD’s must forward approved invoices to the LRP office for final certification and payment. FSD Certified Invoices shall be emailed or faxed as follows: Eastern Regions 1&2 ([email protected] or 703-603-3007; Central Regions 3&4 ([email protected]) or (703-603-3010); Western Regions 5&6 ([email protected] or 703-603-3009). NOTE: Completed LEO Reimbursement Request-Invoices must be stored in locked filing cabinets. Completed forms shall be store in accordance with TSA File Code 2800.15.

SECTION I. INVOICE INFORMATION

Invoice Information

Other Transaction Agreement Number:

Invoice Date:

Airport Name:

Airport Code:

DUNS Number:

Cage Code:

Invoice Number:

TINS Number:

(Each submission requires unique invoice number.)

SECTION II. Invoicing Point of Contact Information

Name:

Address:

Street

City

State

Zip Code

Phone No.:

Fax No.:

Email:

SECTION III. Service Information

Period of Performance - FROM (mm/dd/yyyy):

TO (mm/dd/yyyy):

Description of Services Provided: Checkpoint Coverage

Total No. of LEO Hours Billed:

0.00

Hourly Rate: Rate per Agreement or Actual Rate (whichever is less).

$20.00

Total Reimbursement Request:

$-

Actual Hourly Rate:

$-

Actual Cost of LEO Coverage for Performance Period Submitted:

$-

SECTION IV. Banking Information

Routing Transit No.:

Type of Account:

Depositor Account No.:

Please update all banking information through the System for Award Management/SAM (https://www.sam.gov/portal/public/SAM/). If you experience any issues you may contact the U.S. Coast Guard Finance Center/FINCEN at 866/606-8220 or 757/523-6920 for assistance with the SAMS system and for payment inquiries. Payment status may also be obtained online at https://www.fincen.uscg.mil/secure/HS_PayHist/PH_menu_TSA.htm Our office does not distribute the reimbursable payments directly.

SECTION V. Certifications

I certify that the information provided is true and accurate based on the actual hours performed at the TSA Security Checkpoint(s) and at the hourly rate(s) billed. All information provided is for on-site law enforcement coverage provided to the above mentioned airport in accordance the terms and conditions of the LEO Agreement. I understand that audits may be performed on an unscheduled basis within any given performance period.

Requestor's Authorized Representative

Name (printed):

Contact No.:

Signature:

Date:

FSD of FSD Designee:

Name (printed):

Contact No.:

Signature:

Date:

Previous editions of this form are obsolete.

TSA Form 3503 (2/18) rev. [File: 2800.15] Page 1 of 2

SECTION VI. Checkpoint Log Worksheet

Airport Code:

0

Date

Activity

Total Hours

Base Hourly Rate

Fringe Rate

Total

1

Checkpoint Coverage

$-

2

Checkpoint Coverage

$-

3

Checkpoint Coverage

$-

4

Checkpoint Coverage

$-

5

Checkpoint Coverage

$-

6

Checkpoint Coverage

$-

7

Checkpoint Coverage

$-

8

Checkpoint Coverage

$-

9

Checkpoint Coverage

$-

10

Checkpoint Coverage

$-

11

Checkpoint Coverage

$-

12

Checkpoint Coverage

$-

13

Checkpoint Coverage

$-

14

Checkpoint Coverage

$-

15

Checkpoint Coverage

$-

16

Checkpoint Coverage

$-

17

Checkpoint Coverage

$-

18

Checkpoint Coverage

$-

19

Checkpoint Coverage

$-

20

Checkpoint Coverage

$-

21

Checkpoint Coverage

$-

22

Checkpoint Coverage

$-

23

Checkpoint Coverage

$-

24

Checkpoint Coverage

$-

25

Checkpoint Coverage

$-

26

Checkpoint Coverage

$-

27

Checkpoint Coverage

$-

28

Checkpoint Coverage

$-

29

Checkpoint Coverage

$-

30

Checkpoint Coverage

$-

31

$-

0.00

$-

$-

$-

Please indicate which benefits are included in your average fringe rate. Please also give the percentage or dollar amount for each benefit used.

Fringe Benefits Included:

Yes

No

Social Security

Retirement

Disability Insurance

Workers Compensation

Healthcare Insurance

Pension

Life Insurance

This field will be automatically generated after you enter hours and pay into the large table above.

SECTION VII. Reimbursement Request

Program Functions/Activities

Amount

Programs Outlays to Date

Federal Share Amount

Non-Federal Share Amount

Federal Payments Received To Date

Federal Share Now Requesting

$-

PAPERWORK REDUCTION ACT STATEMENT: Through this information collection, TSA  is gathering information involving the reimbursement of expenses incurred by airport operators for the provision of law enforcement officers (LEOs) to support airport checkpoint screening. The public burden for this collection of information is estimated to be one hour. This is a voluntary collection of information. If you have any comments on the LEO Reimbursement form, you may contact the TSA PRA Officer, 601 S. 12th Street, TSA-901, Arlington, VA 20598-6901-4220. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0063 which expires on 12/31/2018.

Previous editions of this form are obsolete.

TSA Form 3503 (2/18) rev. [File: 2800.15] Page 2 of 2