TSA Form 412 Travel Support Request

DEPARTMENT OF HOMELAND SECURITY

OMB control number 1652-xxxx
Exp. XX/XX/XX

Transportation Security Administration
TRAVEL SUPPORT REQUEST
INSTRUCTIONS: Complete all applicable fields for request consideration. Reference Office of Security Operations
Administrative Directive, Travel Protocol Office. The Transportation Security Operations Center (TSOC) will retain the record and
the Airport will retain a copy in accordance with the TSA Records Disposition Schedules.
SECTION I. Passenger Information
Request Date

Name (first, middle, last )

Internal
Control No.

Official Title

Country

Traveler Coordinator Name

Title
Itinerary Provided

Email

Phone Number

Yes

No

SECTION II. Passenger Flight Information
Departure Airport

a.m.
Date

Airline and Flight Number

Time

Arriving Airport

a.m.
Date

Time

Date

Time

Date

Time

Departure Airport

Airline and Flight Number

Arriving Airport

p.m.
a.m.
p.m.
a.m.

Date

Time

Arriving Airport

p.m.
a.m.

Date

Time

Date

Time

Date

Time

Departure Airport

Airline and Flight Number

p.m.
a.m.

Departure Airport

Airline and Flight Number

p.m.

p.m.
a.m.

Arriving Airport

p.m.
a.m.
p.m.

Previous editions of this form are obsolete.
TSA Form 412 (9/17) rev. [File: 5000.26]

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OMB control number 1652-xxxx
Exp. XX/XX/XX

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
TRAVEL SUPPORT REQUEST
SECTION III. Traveling Party Members
Number of Family

Number of Staff

SECTION IV. Additional Passengers (provide first and last names of all additional traveling passengers.)

SETION V. TSA Travel Protocol Office Contact Information
Telephone: 703-603-0503 Fax: 703-603-1558 Email: [email protected] TSA TPO Liaison
SECTION VI. Notes

Privacy Act Statement: AUTHORITY: 49 USC § 114(f)(15); 49 USC § 44927. PRINCIPAL PURPOSE(S): This information is used to coordinate
and provide airport security screening assistance to eligible travelers. ROUTINE USES(S): This information may be shared in accordance with the
Privacy Act of 1974, 5 USC § 552(a), or for routine uses identified in the TSA system of records, DHS/TSA-001, Transportation Security
Enforcement Record System. DISCLOSURE: Furnishing this information is voluntary; however, failure to provide the requested information may
prevent TSA from providing assistance through airport security screenings to eligible travelers.
Paperwork Reduction Act Statement: The collection involves the submission of travel information to Transportation Security Administration to
provide wounded warrior, severely injured military personnel, and certain other travelers with assistance through the airport security screening
process. This is a voluntary collection. It is estimated that the total average burden per response associated with this collection is approximately
5 minutes. An agency may not conduct, or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
OMB control number. The control number assigned to this collection is OMB 1652-XXXX, which expires XX/XX/XXXX. Send comments regarding
this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to TSA PRA Officer, 601 S.
12th Street, Arlington, VA 20598-6011. ATTN: PRA 1652-XXXX.

TSA Form 412 (9/17) rev. [File: 5000.26]

Previous editions of this form are obsolete.

Page 2 of 2