Form DOT Form DOT Form DOT Service Animal Relief Attestation Form

OMB Control Number: 2105-0576

Expiration Date:__/__ /2027

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: __________________________

Paperwork Reduction Act Burden 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 2105-0576. Public reporting for this collection of information is estimated to be approximately 15 minutes 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 mandatory if an airline requires the submission of the forms (14 CFR 382.75(a) and (b)). 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, U.S. Department of Transportation, 1200 New Jersey Ave., S.E., West Building Ground Floor Room W12-140, Washington, D.C. 20590