Form 2105-NEW (Relief) 2105-NEW (Relief) United States Department of Transportation Service Anima

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it deplays a valid OMB control number. The estimated burden to complete this form is 15 minutes. The OMB control number for this information collection is 2105-NEW. The authority for the collection expires on <<DATE>>

Warning: It is a Federal crime to make materially false, fictitious, or fraudulent statements, entries, or representations knowingly and willfully on this form to secure disability accommodations provided under regulations of the United States Department of Transportation (18 U.S.C. § 1001).

United States Department of Transportation Service Animal

Relief Attestation Form

Service Animal Handler’s Name____________________________________ Phone: _______________________

Service Animal User’s Name (if different Handler): ____________________________ Phone: _________________

Email: ______________________________________________________________________________________

Animal’s Name: ________________________________ Estimated Flight Length: _________________________

Flight Date: _______________ Departure Airport:_________________ Arrival Airport: _____________________

Check one or both boxes:

󠇮 ________________________will not need to relieve itself while on the aircraft.

[Insert Animal’s Name]

󠇮______________________can relieve itself on the aircraft without creating a health/sanitation issue.

[Insert Animal’s Name]

Describe how ________________ will refrain from relieving itself, or relieve itself without posing a

[Insert Animal’s Name]

health/sanitation issue (e.g., the use of a dog diaper):

__________________________________________________________________________________________

__________________________________________________________________________________________

󠇮 I understand that if _________________causes damage, then the airline may charge me for the cost to

[Insert Animal’s Name]

repair it, as long as the airline would also charge passengers without disabilities to repair the same kind of damage.

󠇮 I am signing an official document of the U.S. Department of Transportation. My answers are true to the best of my knowledge. I understand that if I knowingly make false statements on this document, I can be subject to fines and other penalties.

Signature of the handler: ______________________________________ Date: ____________________