According to the Paperwork Reduction Act of 1995, 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 estimated burden to complete this form is 15 minutes. The OMB control number for this information collection is
2105-0576. The authority for the collection expires on December 31, 2023.
Warning: It is a Federal crime to make materially false, fictitious, or fraudulent statements, entries, or representations knowingly and
willfully on this form to secure disability accommodations provided under regulations of the United States Department of Transportation
(18 U.S.C. § 1001).
United States Department of Transportation Service Animal
Relief Attestation Form
Service Animal Handler’s Name Phone:
Service Animal User’s Name (
if different Handler): Phone:
Email:
Animal’s Name: Estimated Flight Length:
Flight Date: Departure Airport: Arriv
al Airport:
Check one or both boxes:
[Insert Animal’s Name]
will not need to relieve itself while on the aircraft.
[Insert Animal’s Name]
_can relieve itself on the aircraft without creating a health/sanitation issue.
Describe how
[Insert Animal’s Name]
will refrain from relieving itself, or relieve itself without posing a
health/sanitation is
sue (e.g., the use of a dog diaper):
I understand that if
[Insert Animal’s Name]
causes damage, then the airline may charge me for the cost to
repair it, as long as the airline would also charge passengers without disabilities to repair the same kind of
damage.
I am signing an official document of the U.S. Department of Transportation. My an
swers are true to the
best of my knowledge. I understand that if I knowingly make false statements on this document, I can be
subject to fines and other penalties.
Signature of the handler: Date:
____________________________________________
______________________________________________
__________________________________________________________________________________________
____________________________________ _______________________
____________________________
_________________
______________________________________________________________________________________
________________________________ _________________________
_______________ _________________ _________
____________
� ________________________
�_____________________
________________
� _________________
�
______________________________________
__________________________
click to sign
signature
click to edit
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