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<td colspan="2"><img src="media/image1.png" /></td>
<td colspan="4"><p><strong>Federal Aviation Administration</strong></p>
<p>U. S. Department of Transportation</p></td>
<td colspan="10"><h1
id="passenger-facility-charge-pfc-application">PASSENGER FACILITY CHARGE
(PFC) APPLICATION</h1></td>
</tr>
<tr class="even">
<td colspan="8"><strong>1. Application Type</strong> <em>(Check all that
apply)</em></td>
<td colspan="3"></td>
<td colspan="4">FAA USE ONLY</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8"><p> a. Impose PFC Charges</p>
<p> b. Use PFC Revenue</p>
<p> c. Amend PFC No. ____________________</p></td>
<td colspan="8"><h2 id="date-received-pfc-number"> Date Received PFC
Number</h2>
<h2 id="section"> _________________________
________________________</h2></td>
</tr>
<tr class="even">
<td colspan="16"><strong>PART I</strong></td>
</tr>
<tr class="odd">
<td colspan="9"><strong>2. Public Agency Name, Address, and Contact
Person</strong></td>
<td colspan="4"><strong>3. Airport(s) to Use</strong></td>
<td colspan="3"><strong>4. Consultation Dates</strong></td>
</tr>
<tr class="even">
<td colspan="9" rowspan="3"><blockquote>
<p>Agency Name ________________________</p>
<p>Address ________________________</p>
<p>City, State, ZIP ________________________</p>
<p>Contact Person ________________________</p>
</blockquote></td>
<td colspan="4" rowspan="3"></td>
<td colspan="3"><strong>a. Date of Written Notice to Air
Carriers:</strong></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>b. Date of Consultation Meeting with
Air</strong></p>
<p><strong>Carriers:</strong></p></td>
</tr>
<tr class="even">
<td colspan="3"><strong>c. Date of Public Notice</strong></td>
</tr>
<tr class="odd">
<td colspan="16"><strong>PART II</strong></td>
</tr>
<tr class="even">
<td colspan="16"><strong>5. Charges</strong></td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="3">a. Airport to Impose</td>
<td colspan="3">b. Level</td>
<td colspan="4"><p>c. Total Estimated PFC</p>
<p>Revenue by Level</p></td>
<td colspan="3" rowspan="3"><p>d. Proposed Effective</p>
<p>Date:</p></td>
<td rowspan="3"><p>e. Estimated Expiration</p>
<p>Date:</p></td>
</tr>
<tr class="even">
<td colspan="3"> $1.00 $2.00 $3.00</td>
<td colspan="4"><p>Impose</p>
<p>Use</p></td>
</tr>
<tr class="odd">
<td colspan="3"> $4.00 $4.50</td>
<td colspan="4"><p>Impose</p>
<p>Use</p></td>
</tr>
<tr class="even">
<td colspan="16"><strong>PART III</strong></td>
</tr>
<tr class="odd">
<td colspan="16"><strong>6. Attachments</strong> <em>(Check all that
Apply)</em></td>
</tr>
<tr class="even">
<td colspan="3"><blockquote>
<p><strong>Attached</strong></p>
</blockquote></td>
<td colspan="7"><h2 id="submitted-with-application-number">Submitted
with Application Number</h2></td>
<td colspan="6"><h2 id="document">Document</h2></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>a.</p>
<p>b.</p>
<p>c.</p>
<p>d.</p>
<p>e.</p>
<p>f.</p>
<p>g.</p>
<p>h.</p>
<p>i.</p>
</blockquote></td>
<td colspan="3"><blockquote>
&#10;</blockquote></td>
<td colspan="6"><h2 id="section-1">
________________________________</h2>
<h2 id="section-2"> ________________________________</h2>
<p> ________________________________</p>
<p> ________________________________</p>
<p> ________________________________</p>
<p> ________________________________</p>
<p> ________________________________</p>
<p> ________________________________</p>
<p> ________________________________</p></td>
<td colspan="6"><p>Airport Capital Improvement Plan</p>
<p>Project Information (Attachment B)</p>
<p>Air Carrier Consultation and Public Notice Information</p>
<p>Request to Exclude Class(es) of Carriers</p>
<p>Alternative Uses/Projects</p>
<p>Competition Plan/Update</p>
<p>ALP/Airspace/Environmental</p>
<p>Notice of Intent Project Information</p>
<p>________________________________</p></td>
</tr>
<tr class="even">
<td colspan="16"><strong>PART IV</strong></td>
</tr>
<tr class="odd">
<td colspan="16"><p><strong>7. With respect to this PFC application I
hereby certify as follows:</strong></p>
<blockquote>
<p>To the best of my knowledge and belief, all data in this application
are true and correct;</p>
<p>This application has been duly authorized by the governing body of
the public agency;</p>
<p>The public agency will comply with the assurances (Appendix A to Part
158) if the application is approved;</p>
<p>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.</p>
<p>If required, the public agency has submitted a competition plan in
accordance with 49 U.S.C. 47106(f); and</p>
<p>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.</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2">a. Typed Name of Authorized
Representative</td>
<td colspan="7">b. Title</td>
<td colspan="2">c. Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="7">d. E-mail Address</td>
<td colspan="2">e. Fax Number</td>
</tr>
<tr class="even">
<td colspan="14">f. Signature of Authorized Representative</td>
<td colspan="2">g. Date Signed</td>
</tr>
<tr class="odd">
<td colspan="16"><strong>Paperwork Reduction Act Statement:</strong>
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.</td>
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