Form TSA Form 3503 (1/1 TSA Form 3503 (1/1 LEO Reimbursement Request-Invoice

	Department of Homeland Security Transportation Security Administration LEO Reimbursement Request-Invoice
	INSTRUCTIONS: This form is to be submitted monthly by participants of the Law Enforcement Officer (LEO) Reimbursement Program (LRP). An invoice is required for each Period of Performance for which payment is sought. All submissions must be accompanied by supporting documentation demonstrating actual cost/outlay for services provided (e.g. payroll report, ledger, etc.). The completion of Section VI and/or the submission of checkpoint logs, timesheets, etc. are not a substitute for documentation of actual cost. Completion of all fields is required. LEO Reimbursement Program Invoices must be submitted to the local TSA Federal Security Director (FSD) for signature. FSD’s must forward approved invoices to the LRP office for final certification and payment. FSD Certified Invoices shall be emailed or faxed as follows: Eastern Regions 1&2 (lrp-efax-east@tsa.dhs.gov or 703-603-3007; Central Regions 3&4 (lrp-efax central@tsa.dhs.gov or 703-603-3010); Western Regions 5&6 (lrp-efax-west@tsa.dhs.gov or 703-603-3009). NOTE: Completed LEO Reimbursement Request-Invoices must be stored in locked filing cabinets.
	SECTION I. INVOICE INFORMATION
	Other Transaction Agreement Number:						Invoice Date:
	Airport Name:						Airport Code:
	DUNS Number:				Cage Code:		Invoice Number:
	TINS Number:						(Each submission requires unique invoice number.)
	SECTION II. INVOICING POINT OF CONTACT INFORMATION
	Name:
	Address:
	Street					City		State		Zip Code
	Phone No.:				Fax No.:				Email:
	SECTION III. SERVICE INFORMATION
	Period of Performance: From(mm/dd/yy):							To(mm/dd/yy):
	Description of Services Provided: Checkpoint Coverage
	Total No. of LEO Hours Billed:				Hourly Rate: Rate per Agreement or Actual Rate (whichever is less).				Total Reimbursement Request:			$-
	Actual Hourly Rate:					Actual Cost of LEO Coverage for Performance Period Submitted:
	SECTION IV. BANKING INFORMATION
	Routing Transit No.:								Type of Account:
	Depositor Account No.:
	Please update all banking information through the System for Award Management/SAM (https://www.sam.gov/portal/public/SAM/). If you experience any issues you may contact the U.S. Coast Guard Finance Center/FINCEN at 866/606-8220 or 757/523-6920 for assistance with the SAMS system and for pament inquiries. Payment status may also be obtained online at https://www.fincen.uscg.mil/secure/HS_PayHist/PH_menu_TSA.htm Our office does not distribute the reimbursable payments directly.
	SECTION V. CERTIFICATIONS
	I certify that the information provided is true and accurate based on the actual hours performed at the TSA Security Checkpoint(s) and at the hourly rate(s) billed. All information provided is for on-site law enforcement coverage provided to the above mentioned airport in accordance the terms and conditions of the LEO Agreement. I understand that audits may be performed on an unscheduled basis within any given performance period.
	REQUESTOR'S AUTHORIZED REPRESENTATIVE
	Name (printed):								Contact No.:
	Signature:								Date:
	FSD of FSD Designee:
	Name (printed):								Contact No.:
	Signature:								Date:
	PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: Through this information collection, TSA  is gathering information involving the reimbursement of expenses incurred by airport operators for the provision of law enforcement officers (LEOs) to support airport checkpoint screening. The public burden for this collection of information is estimated to be one hour. This is a voluntary collection of information. If you have any comments on the LEO Reimbursement form, you may contact the TSA PRA Officer, 601 S. 12th Street, TSA-901, Arlington, VA 20598-6901-4220. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0063 which expires on 11/30/2015.
	SECTION VI. CHECKPOINT LOG - WORKSHEET
	AIRPORT CODE:
	DATE		ACTIVITY		TOTAL HOURS		BASE HOURLY RATE		FRINGE RATE		TOTAL
	1										$-
	2										$-
	3										$-
	4										$-
	5										$-
	6										$-
	7										$-
	8										$-
	9										$-
	10										$-
	11										$-
	12										$-
	13										$-
	14										$-
	15										$-
	16										$-
	17										$-
	18										$-
	19										$-
	20										$-
	21										$-
	22										$-
	23										$-
	24										$-
	25										$-
	26										$-
	27										$-
	28										$-
	29										$-
	30										$-
	31										$-
					0.00		$-		$-		$-
	Please indicate which benefits are included in your average fringe rate. Please also give the percentage or dollar amount for each benefit used.
	Fringe Benefits Included:					Yes				No
	Social Security
	Retirement
	Disability Insurance
	Workers Compensation
	Healthcare Insurance
	Pension
	Life Insurance
	Fringe Benefits are an added _____% on top of the base salary.
	SECTION VII. - REIMBURSEMENT REQUEST
	PROGRAM FUNCTION/ACTIVITIES								Amount
	Programs Outlays to Date
	Federal Share Amount
	Non-Federal Share Amount
	Federal Payments Received To Date
	Federal Share Now Requesting
	*Please note the federal payments requested column is now changed to federal payment received to date. **Program Outlay to date should reflect from the beginning of the current agreement period to date.