TSA Form 419D CCSF Principal Attestation

DEPARTMENT OF HOMELAND SECURITY
TRANSPORTATION SECURITY ADMINISTRATION

OMB 1652-0053
Exp. 09/30/2024

CERTIFIED CARGO SCREENING FACILITY (CCSF)
SENIOR MANAGER OR REPRESENTATIVE
INSTRUCTIONS: This form is to be completed by senior managers or representatives of a
company seeking to be part of the Certified Cargo Screening Program. Please complete the
applicable section and sign and date the form. This form must be submitted along with other parts
of the CCSF application as a complete package via email as a PDF to
[email protected].
A complete CCSF application package includes TSA Form 419A CCSF Letter of Intent, TSA Form
419B CCSF Facility Profile Application, TSA Form 419C CCSF SSI Agreement, TSA Form 419D
CCSF Principal Attestation, and TSA Form 419E Security Profile.
Section 1. Previously Certified, but Revoked
In accordance with 49 CFR 1549.7(a)(1)(iii) I
was /
was not a senior manager or
representative of a facility that had its security program withdrawn by TSA.

CCSF Number
Physical City, State
My certification was revoked for the following reason(s):

Date Revoked

Section 2. Not Previously Certified
I certify that I have NOT previously been a proprietor, general partner, officer, director, or owner
(as defined in 49 CFR 1548.16) of an IAC or senior manager or representative of a CCSF (49 CFR
1549.7(a)(1)(ii)).
Section 3. Signature

Applicant Printed Name

Applicant Signature

Date

Previous editions of this form are obsolete.

Page 1 of 1

PAPERWORK REDUCTION ACT BURDEN STATEMENT: TSA is collecting this information to qualify entities as Certified Cargo Screening
Facilities. The public burden for this collection of information is estimated to be approximately 30 minutes. 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 1652-0053, 6595
Springfield Center Drive, Springfield, VA 20598. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0053, which
expires 09/30/2024.
TSA Form 419D, (04/11) [File: #2000.2]
OMB control number 1652-0053; Expiration Date: 09/30/2024