Form TSA Form 419H TSA Form 419H AVIATION SECURITY KNOWN SHIPPER VERIFICATION

OMB control number 1652-0040

Exp. 04/30/2024

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

AVIATION SECURITY KNOWN SHIPPER VERIFICATION

INSTRUCTIONS: This form must be completed in its entirety by approved verification firms for the Known Shipper Program and provided to TSA upon request. Print clearly in all fields except the signature lines.
SECTION I. Facility and Contact Data
Date of Physical Visit		Name of Business Visited
Also doing business as (trade name)				Business Type
Number of Years in Business				Employee's Identifying Number
Name of Individual Contacted				Title
SECTION II. Address Information
Physical Address	City				State	Zip
Mailing Address (if different)	City				State	Zip
SECTION III. Shippers Contact Information
Physical Location Phone Number			Principal Contact Phone Number
Emergency Phone Number			Fax Number
Email Address			Web Address
SECTION IV. Transfer of Cargo
Name and title of employee or authorized representative verifying the above information: I certify the above information is true and correct and the onsite visit and verification was conducted in person as required by the TSA standard security program applicable security directives. This certification (i) is made with the understanding that any intentional falsification maybe subject to both civil and criminal penalties under 49 CFR 1540.103 and 18 U.S.C. 1001 (ii) subject to record keeping requirements approved by TSA.
Printed Full Name of Verifier					Date
Signature of Verifier					Date
Printed Full Name of Shipper					Date
Signature of Shipper					Date

PAPERWORK REDUCTION ACT BURDEN STATEMENT: TSA is collecting this information to qualify entities as Known Shipper. The public burden for this collection of information is estimated to be approximately 1 hour. This is a mandatory collection of information. Send comments regarding this burden estimate or any other aspect of this collection to: TSA-11, Attention: PRA 1652-0040, 6595 Springfield Center Drive, Springfield, 20598-6011. An agency may not conduct or sponsor, any persons not required to respond to, a collection of information unless it displays a current valid OMB control number. The OMB control number assigned to this collection is 1652-0040, which expires 04/30/2024.

Previous editions of this form are obsolete

TSA Form 419H (8/17) rev. [File: 400.18] Page 1 of 1