5500-3 PFC Financial Completion Form

OMB Control Number: 2120-0557

Expiration Date: 11/30/2024

Paperwork Reduction Act 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 2120-0557. Public reporting for this collection of information is estimated to be approximately 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 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(h)). 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.

FAA Form 5500-3

Instructions: This form is populated with information that has been previously submitted to the Federal Aviation Administration via the quarterly reports. Confirm the information is correct, fill in any missing information, sign the form, and submit the form to the FAA upon application close out.

PASSENGER FACILITY CHARGE

Closeout – Application Report

Public Agency: {Public Agency Name}

Address: {Public Agency Address}

Impose Airport: {Impose Airport Name}

Use Airport: {Use Airport Name}

Date: {Date}

Application Number: {PFC Application Number}

Application Approval Date: {Approval Date}

Number of Amendments: {Number of Amendments} Total Approved Authority: {Total Approved}

Charge Effective Date: {Charge Effective Date} Total PFC Revenue: {Total Revenue}

Charge Expiration Date: {Charge Expiration Date} PFC Funds Disbursed: {Total Disbursed}

Project Number	Project Title	PFC Revenue Approved				Project Disbursed	Total Project Costs	Financial Completion Date	Financing Start Date	Maturity / Finish Date	AIP Funding
		Pay-as-you-go	Bond Capital	Financing	Total PFC
Application Total

Certification:

I hereby certify that these projects have been accomplished under the Passenger Facility Charge Program. This certification affirms that all applicable regulations under 14 CFR Part 158 have been met, and that, to the best of my knowledge, the responses to the above items are correct and that the attachments, if any are both correct and complete.

Submitted By: Accepted By:

_____________________________________________ ___________ _____________________________________ _________

Public Agency Authorized Representative Date FAA Representative Date

___________________________________________________________ _________________________________________________

Typed Name and Title of Public Agency Representative FAA Field Office

FAA Comments: