Form TSA Form 412 TSA Form 412 Travel Support Request

OMB control number 1652-0069
Exp.04/30/2025
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration

TRAVEL SUPPORT REQUEST
INSTRUCTIONS: Complete all applicable fields for request consideration. Reference Security Operations Administrative Directive,
Travel Protocol Office. The completed Form may be submitted to [email protected]. The Transportation Security Operations
Center (TSOC) will retain the record and the Airport will retain a copy in accordance with the TSA Records Disposition Schedules.
Section I. TSA Travel Protocol Office Contact Information
Phone:

703-603-1558

Email:

[email protected]

TPO Employee Name:

Internal Control Number:

Section II. Passenger Information
Request Date:

Name (first, middle, last):

Official Title:

Country:

Travel Coordinator Name:

Title:

Email:

Phone Number:

Depart Airport

Airline

Flight #

Flight Itinerary
Depart Time
Arrival Time

Itinerary Provided
Yes
No
Arrival Airport

Date of Travel

Additional Passengers (provide first and last names of all additional traveling passengers.)

NOTES

Privacy Act Statement: AUTHORITY: 49 U.S.C. § 44927. PRINCIPAL PURPOSE(S): This information is used to coordinate and
provide airport security screening assistance to eligible travelers. ROUTINE USE(S): This information may be shared in accordance
with the Privacy Act of 1974, 5 U.S.C. §552(a), or for routine uses identified in the TSA system of records, DHS/TSA-001,
Transportation Security Enforcement Record System. DISCLOSURE: Furnishing this information is voluntary; however, failure to
provide the requested information may prevent TSA from providing assistance through airport security screenings to eligible travelers.
Paperwork Reduction Act Statement: The collection involves the submission of travel information to Transportation Security
Administration to provide wounded warrior, severely injured military personnel, and certain other travelers with assistance through the
airport security screening process. This is a voluntary collection. It is estimated that the total average burden per response associated
with this collection is approximately 5 minutes. An agency may not conduct, or sponsor, and a person is not required to respond to, a
collection of information unless it displays a valid OMB control number. The control number assigned to this collection is OMB 16520069 which expires 04/30/2025. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing this burden to TSA PRA Officer, 6595 Springfield Center Drive, Springfield, VA 22150. ATTN: PRA
1652- 0069.
Previous editions of this Form are obsolete
TSA Form 412 (12/24) rev. [File: 400.7.1]

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