5500-4 PFC Physical Completion Form

OMB Control Number: 2120-0557

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.

Expiration Date: 11/30/2024

FAA Form 5500-4

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, sign the form, and submit the form to the FAA upon application close out.

PASSENGER FACILITY CHARGE

Closeout - Project Physical Completion Certification

ALL PROJECTS FOR WHICH IMPOSE AND USE OR USE AUTHORITY IS REQUESTED IN THE APPLICATION MUST BE LISTED UNDER THE APPROPRIATE TYPE OF FUNDING BELOW

Public Agency: {Public Agency Name}

Airport Name: {Airport Name}

PFC Application: {PFC Application Number}

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{Project Type}

Project Completion Date

{Project Title} {Project Completion Date}

{Project Type Certifications, if applicable}

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I hereby certify that these project(s) have been accomplished in accordance with the Passenger Facility Charge Program. This certification affirms that all applicable regulations under Part 158 have been met, and that, to the best of my knowledge, the responses to the above items, as marked, are correct and that the attachments, if any are both correct and complete.

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Public Agency Authorized Representative Date

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Typed Name and Title of Public Agency Representative

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Name Routing Symbol Date