Form 5500-1 Passenger Facility Charge (PFC) Application

U.S. Department
of Transportation
Federal Aviation
Administration

Passenger Facility Charge Application, Form 5500-1
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 to 80 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and 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: Information Collection Clearance Officer,
Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.

Instructions for Preparation
of Passenger Facility Charge (PFC) Application, Form 5500-1

1. Application Type (Check all that apply)
a. Impose PFC Charges. Check this box when applying for authority to
impose.
b. Use PFC Revenues. Check this box when: (1) applying for authority to
use where the authority to impose a PFC has previously been approved or
(2) applying for authority to impose and authority to use concurrently.
c. Amend PFC No. Check this box when proposing to amend an approved
PFC. Enter the PFC number for the original application assigned by the
Federal Aviation Administration (FAA).

FAA Form 5500-1 (12/20) SUPERSEDES PREVIOUS EDITION

Page i of iv

PART I – General
2. Public Agency Name, Address, and Contact Person. Enter the legal name
and full address of the public agency as well as the name of a person to contact
concerning the application. Do not list the name of the airport.
3. Airport(s) to Use. Enter the official name or location identifier (LOCID) of the
airport(s) at which a PFC financed project is proposed. List all airports where
PFCs are proposed for use in this application.
4. Consultation Dates
a. Date of Written Notice to Air Carriers. Enter the date the written notice
was provided to air carriers as required by 14 CFR Part 158,
section 158.23(a).
b. Date of Consultation Meeting with Air Carriers. Enter the date of the
consultation meeting as required by 14 CFR Part 158, section
158.23(a)(4).
c. Date of Public Notice. Enter the date of the public notice as required by
14 CFR Part 158, section 158.24.
PART II – Charges
5. Charges
a. Airport to Impose. Enter the official airport name at which the PFC is to
be imposed.
b. Level. Check the block(s) that reflect the PFC amount(s) to be imposed.
A public agency may request multiple PFC levels for projects within an
application.
c. Total Estimated PFC Revenue. Enter the total PFC revenue estimated to
be collected and/or used as a result of this application.
d. Proposed Effective Date. Enter the proposed charge effective date,
which is the date air carriers are expected to begin collecting this PFC.
For a use application, enter the date collections began for the impose
authority.
e. Estimated Expiration Date. Enter the proposed charge expiration date,
which is the date the public agency expects to have collected the total
amount, and thus, the air carriers are expected to cease collecting the
PFC. For a use application, enter the date collections for the application’s
impose authority expire.

FAA Form 5500-1 (12/20) SUPERSEDES PREVIOUS EDITION

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PART III – Attachments
6. Attachments (check all that apply). Check each block that applies to the
application being submitted. For “Use only” and amendment applications, check
each block that applies for an attachment that has been submitted with a
previously approved application. For each block checked, provide the application
number with which the attachment was submitted.
a. Airport Capital Improvement Plan. Indicate if a copy of the airport
capital plan or other documentation of planned improvements for each
airport at which a PFC financed project is proposed is attached in
accordance with 14 CFR Part 158, sections 158.17 and 158.25(b)(5).
b. Application Project Information. Indicate if the project information
(Attachment B) set forth in 14 CFR Part 158, sections 158.25(b)(1)
through (b)(10), is attached.
c. Air Carrier Consultation and Public Notice Information. Indicate if the
consultation and notification information set forth in 14 CFR Part 158,
sections 158.25(b)(11) through (b)(14) is attached.
d. Request to Exclude Class(es) of Carriers. Indicate if a list of any class
or classes of carriers that would not be required to collect a PFC, as set
forth in 14 CFR Part 158, section 158.25(b)(12)(iv), is attached.
e. Alternate Uses/Projects. For any application to impose a PFC that is not
accompanied by a concurrent application to use PFC revenue, indicate if a
description of alternative uses of the PFC revenue, as set forth in 14 CFR
Part 158, section 158.25(b)(15), is attached.
f. Competition Plan/Update. In accordance with 14 CFR Part 158, section
158.25(b)(7), for any application with a terminal development project at a
covered airport, indicate if a competition plan in accordance with 14 CFR
Part 158, section 158.19 is attached.
g. ALP/Airspace/Environmental. Indicate if a copy of the Airport Layout
Plan (ALP), Airspace, and Environmental Findings, as set forth in 14 CFR
Part 158, sections 158.25(c)(1) and (c)(2), is attached.
h. Notice of Intent Project Information. Indicate if the project information
that a public agency must file to notify the FAA of its intent to impose a
PFC (Attachment H) is attached.
i.

Other. Indicate if any other documents are attached.

FAA Form 5500-1 (12/20) SUPERSEDES PREVIOUS EDITION

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PART IV – Certification
7. With Respect to this PFC Application. By signing this application, the public
agency agrees to abide by all PFC assurances and certifies that all information
contained in the application is true and correct.
a. Name of Authorized Representative. Indicate the name of the individual
signing the application form. The individual must be an authorized official
of the public agency.
b. Title. Enter the title of the Authorized Representative entered in 7.a.
c. Telephone Number. Enter the telephone number, including the area
code, of the Authorized Representative.
d. E-mail Address. Enter the e-mail address of the Authorized
Representative.
e. Signature of Authorized Representative. The Authorized
Representative may sign this application electronically.
f. Date Signed. Enter the date the Authorized Representative signed the
application form.

Instructions for Submitting Form 5500-1
and Obtaining Additional Information
Submit one electronic copy or two paper copies of the application and all
attachments to the local FAA Airports Office. Go here for local office information:
https://www.faa.gov/about/office_org/headquarters_offices/arp/regional_offices/.
For questions about this form, contact the local FAA Airports Office or direct
questions to the following address:
Federal Aviation Administration
Financial Analysis and PFC Branch, APP-510
800 Independence Avenue SW
Washington, DC 20591
Additional information is available at: https://www.faa.gov/airports/pfc/.

FAA Form 5500-1 (12/20) SUPERSEDES PREVIOUS EDITION

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Federal Aviation Administration
U. S. Department of Transportation

OMB Approved 2120-0557
Exp. 12/31/2020

PASSENGER FACILITY CHARGE (PFC) APPLICATION
FAA USE ONLY

1. Application Type (Check all that apply)
a. Impose PFC Charges

Date Received:

b. Use PFC Revenue

PFC Number:

c. Amend PFC No.

PART I - General
3. Airport(s) to Use

2. Public Agency Name, Address, and Contact Person

4. Consultation Dates
a. Date of Written Notice to Air
Carriers:

Agency Name:
Address:
City, State, ZIP:

b. Date of Consultation Meeting with
Air Carriers:

Contact Person:

c. Date of Public Notice:

PART II - Charges
5. Charges
a. Airport to Impose:

b. Level
$1.00

$2.00

$4.00

$4.50

$3.00

c. Total Estimated
PFC Revenue

d. Proposed Effective
Date:

e. Estimated Expiration
Date:

Impose:
Use:

PART III - Attachments
6. Attachments (Check all that Apply)
a. Airport Capital Improvement Plan

Attached

Submitted with Application Number:

b. Application Project Information

Attached

Submitted with Application Number:

c. Air Carrier Consultation and Public Notice Information

Attached

Submitted with Application Number:

d. Request to Exclude Class(es) of Carriers

Attached

Submitted with Application Number:

e. Alternative Uses/Projects

Attached

Submitted with Application Number:

f. Competition Plan/Update

Attached

Submitted with Application Number:

g. ALP/Airspace/Environmental

Attached

Submitted with Application Number:

h. Notice of Intent Project Information

Attached

Submitted with Application Number:

I. Other:

Attached

Submitted with Application Number:

PART IV - Certification
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. Name of Authorized Representative

b. Title

c. Telephone Number

d. E-mail Address
Please read the following information: By signing this document, you are agreeing that you have reviewed the following disclosure information
and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic
signatures in lieu of using paper documents. You are not required to receive notices and disclosures or sign documents electronically. If you prefer
not to do so, you may request to receive paper copies and withdraw your consent at any time.
e. Signature of Authorized Representative

FAA Form 5500-1 (12/20) SUPERSEDES PREVIOUS EDITION

f. Date Signed