BTS | Passenger Civil Aviation Security Service Fees - (September 11 (th) Security Fees)

Passenger Civil Aviation Security Service Fees
(September 11^th Security Fees)
Quarterly Report Form

Submitter Information

Name (Last, First, M.I.)

Telephone no.

Address

Airline Information

Carrier Name

Carrier Code

Reporting Period

Year (YYYY)	Quarter (Check one)
	1^st	2^nd	3^rd	4^th

Monthly Transportation Security Fees

Month:
Monthly security fees imposed on passengers.
Monthly security fees collected from passengers.
Monthly security fees refunded to passengers.
Monthly security fees remitted to the Transportation Security Administration.

Imposed: Charge of $2.50 applied to each enplanement eligible for the fee on air transportation sold.

Collected: Actual total amount of these fees collected from passengers.

Refunded: Fees refunded to passengers (for example change in reservations, over-collection, cancellation, etc.).

Remitted: Total fees paid to TSA.

_________________________
Signature

_____/_____/_____
Date (MM/DD/YYYY)