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 man 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, 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: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.

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

1. Application Type (Choose all that apply)

   1. Impose PFC Charges. Check this box when applying for authority to impose.

   2. 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.

   3. 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).

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 of the airport or airports at which a PFC financed project is proposed. List all airports where PFCs are proposed for use in this application.

4. Consultation Dates

   1. 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).

   2. 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).

   3. Date of Public Notice. Enter the date of the public notice as required by 14 CFR Part 158, section 158.24.

5. Charges

   1. Airport to Impose. Enter the official airport name at which the PFC is to be imposed.

   2. Level. Check the blocks that reflect the PFC amount(s) to be imposed. A public agency may request a charge amount from each of the two levels.

   3. Total Estimated PFC Revenue by Level. Enter the total PFC revenue estimated to be collected and/or used as a result of this application. A public agency applying for a PFC at the $4.00 and $4.50 level should separate the impose and/or use total(s) from the total for project(s) requested at the $1.00, $2.00 or $3.00 level.

   4. 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.

   5. 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.

6. Attachments (check all that apply)

   1. Attached. Check each block that applies to the application being submitted.

   2. Submitted with Previous Application Dated. (For “Use only” and amendment applications) Check each block that applies (i.e., the attachment has been submitted with a previously approved application). For each block checked, provide the date of the application with which the attachment was submitted.

7. With Respect to this PFC Application

   1. Type Name of Authorized Representative. Self-explanatory.

   2. Title. Enter the title of the Authorized Representative entered in 7.a.

   3. Telephone Number. Enter the telephone number, including the area code, of the Authorized Representative.

   4. E-mail Address. Enter the e-mail address of the Authorized Representative or public agency PFC contact.

   5. Signature of Authorized Representative. This application may be signed electronically. Note: 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.

   6. Date Signed. Self-explanatory.

Submit two paper copies or one electronic copy of the application and all attachments to the local FAA Airports Office.

Contact the local FAA Airports Office for questions about this form or direct questions to the following address:

Federal Aviation Administration
Financial Analysis and PFC Branch, APP-510
800 Independence Avenue SW
Washington, DC 20591

For more information, visit https://www.faa.gov/airports/pfc/.

Federal Aviation Administration U. S. Department of Transportation

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

PASSENGER FACILITY CHARGE (PFC) APPLICATION
1. Application Type (Check all that apply) a. Impose PFC Charges b. Use PFC Revenue c. Amend PFC No.			FAA USE ONLY
			Date Received: PFC Number:
PART I - General
2. Public Agency Name, Address, and Contact Person Agency Name: Address: City, State, ZIP: Contact Person:			3. Airport(s) to Use		4. Consultation Dates a. Date of Written Notice to Air Carriers: b. Date of Consultation Meeting with Air Carriers: c. Date of Public Notice:
PART II - Charges
5. Charges
a. Airport to Impose:	b. Total Estimated PFC Revenue by Level Impose Use: $1.00 $2.00 $3.00 Impose Use: $4.00 $4.50			c. Proposed Effective Date:		d. Estimated Expiration Date:
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					f. Date Signed