OMB Approved 2120-0557 Exp. 3/31/2010 Federal Aviation Administration PASSENGER FACILITY CHARGE (PFC) APPLICATION U. S. Department of Transportation 1. Application Type (Check all that apply) FAA USE ONLY a. Impose PFC Charges Date Received PFC Number b. Use PFC Revenue c. Amend PFC No. ____________________ _________________________ ________________________ PART I 2. Public Agency Name, Address, and Contact Person Agency Name ________________________ 4. Consultation Dates a. Date of Written Notice to Air Carriers: ________________________ Address 3. Airport(s) to Use b. Date of Consultation Meeting with Air Carriers: City, State, ZIP ________________________ c. Date of Public Notice Contact Person ________________________ PART II 5. Charges a. Airport to Impose b. Level $1.00 c. Total Estimated PFC Revenue by Level Impose $2.00 d. Proposed Effective Date: e. Estimated Expiration Date: $3.00 Use Impose $4.00 $4.50 Use PART III 6. Attachments (Check all that Apply) Attached Submitted with Application Number a. ________________________________ b. ________________________________ c. ________________________________ d. ________________________________ e. ________________________________ f. ________________________________ g. ________________________________ ________________________________ h. i. ________________________________ Document Airport Capital Improvement Plan Project Information (Attachment B) Air Carrier Consultation and Public Notice Information Request to Exclude Class(es) of Carriers Alternative Uses/Projects Competition Plan/Update ALP/Airspace/Environmental Notice of Intent Project Information ________________________________ PART IV 7. With respect to this PFC application I hereby certify as follows: To the best of my knowledge and belief, all data in this application are true and correct; This application has been duly authorized by the governing body of the public agency; The public agency will comply with the assurances (Appendix A to Part 158) if the application is approved; For those projects for which approval to use PFC revenue is requested, all applicable ALP approvals, airspace determinations, and environmental reviews required by the National Environmental Policy Act have been completed. If required, the public agency has submitted a competition plan in accordance with 49 U.S.C. 47106(f); and If required by 49 U.S.C. 40117(d)(4), adequate provision for financing the airside needs, including runways, taxiways, aprons, and gates, has been made by the public agency. a. Typed Name of Authorized Representative c. Telephone Number d. E-mail Address f. Signature of Authorized Representative b. Title e. Fax Number g. Date Signed Paperwork Reduction Act Statement: This form is the FAA's primary source for collecting information for the authority to collect PFC revenue for airport development. This information is used to determine the eligibility and justification of airport development projects regarding safety, security, or capacity of the national air transportation system; or which reduce noise or mitigate noise impacts resulting from an airport; or furnish opportunities for enhanced competition between or among air carriers. It is estimated that it will take approximately 5-80 hours to fill out the application depending on the complexity. The use of the form is required to obtain FAA approval of authority to collect PFC revenue (49 U.S.C. 40117(c)). No assurance of confidentiality is necessary or provided. It should be noted that an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with this collection of information is 2120-0557. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC, 20591, Attn: Information Collections Clearance Officer, AIO-20. FAA Form 5500-1 (3-07) Supersedes Previous Edition American LegalNet, Inc. www.FormsWorkflow.com