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Eligibility Statement Amateur Built Aircraft FAA 8130-12 - Official Federal Forms
| Eligibility Statement Amateur Built Aircraft Form. This is a national form and can be used in Federal Aviation Administration (FAA) . |
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ELIGIBILITY STATEMENT AMATEUR-BUILT AIRCRAFT U.S. Department of Transportation Federal Aviation Administration Supplemental Information and Instructions INFORMATION FOR APPLICANT Privacy Act Statement Information on FAA Form 8130-12, Eligibility Statement, Amateur-Built Aircraft is solicited under the authority of 49 U.S.C. 44103 as implemented by 14 CFR Part 21. The purpose of this information is for the applicant to certify that the major portion of the aircraft was fabricated and assembled for their own education or recreation. Submission of this data is mandatory and will become part of the Privacy Act system of records DOT/FAA 801, Aircraft Registration System. Incomplete submission may result in delay or denial of your request. Information maintained in the Privacy Act system of records is routinely used to (1) provide aircraft owners and operators information about potential mechanical defects or unsafe conditions of their aircraft in the form of airworthiness directives, (2) locate specific individuals or aircraft for accident investigation, violation, or safety related requirements, (3) prepare an Aircraft Registry in magnetic tape and microfiche form as required by ICAO agreement, containing information on aircraft owners by name, address, United States Registration Number, and type of aircraft, and (4) DOT Prefatory Statement of General Routine Uses. Paperwork Reduction Act Statement: This information is collected for the purpose of issuing a special airworthiness certificate for the purpose of operating and amateur-built aircraft to any applicant meeting the criteria established in FAA Order 8130-2, Airworthiness Certification of Aircraft and Related Products. The FAA uses the information to maintain and update the current database of aircraft having obtained approved airworthiness certificates. The burden associated with completing FAA Form 8130-12 is 15 minutes. Providing this information is mandatory if an applicant wishes to obtain a special airworthiness certificate for the purpose of operating an amateur-built aircraft. The information is protected under the provisions of the Privacy Act and the Privacy Act system of records DOT/FAA-801, Aircraft Registration System. 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 2120-0018. 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 Collection Clearance Officer, AES-200. Tear off this cover sheet before submitting form. FAA Form 8130-12 (08-2009) Supersedes Previous Edition NSN:0052-00-889-9002 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB NO. 2120-0018 Exp. 12/31/2010 US Department of Transportation Federal Aviation Administration ELIGIBILITY STATEMENT AMATEUR-BUILT AIRCRAFT Instructions: Print or type all information except signature. Submit original to an authorized FAA representative. Applicant completes Section I thru III. Notary Public Completes Section IV. I. REGISTERED OWNER INFORMATION Name(s) Address(es) No. & Street Telephone No.(s) City State Zip ( ) Residence ( II. AIRCRAFT INFORMATION ) Business Model Assigned Serial No. Registration No. Aircraft Fabricated: Plan Kit Engine(s) Make Engine(s) Serial No. Prop./Rotor(s) Make Prop./Rotor(s) Serial No.(s) III. MAJOR PORTION ELIGIBILITY STATEMENT OF APPLICANT I certify that the major portion of this aircraft (identified in Section II above) was fabricated and assembled by Names of all builders (Please Print) solely for my (our) education or recreation, in accordance with 14 CFR part 21, Certification Procedures for Products and Parts, ยง 21.191(g), Operating amateur-built aircraft. I have records to support this statement and will make them available to the FAA upon request. During the fabrication and assembly of this project, I/ we used the following commercial assistance (mark N/A if no commercial assistance was used): ____________________________ Name of company or individual(s) ____________________________ Name of company or individual(s) _____________________ City & State ______________________ City & State ______________ Phone ______________ Phone -NOTICEWhoever in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or who makes any materially false, fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing the same to contain any materially false, fictitious or fraudulent statement or entry, shall be fined under this title, imprisoned not more than 5 years or, if the offense involves international or domestic terrorism, imprisoned not more than 8 years, or both. (U.S. Code, Title 18, Sec. 1001) APPLICANT'S DECLARATION I hereby certify that all statements and answers provided by me in this statement form are complete and true to the best of my knowledge, and I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and understand the Privacy Act statement that accompanies this form. Signature of Applicant (In Ink) Date IV. NOTARIZATION STATEMENT FAA Form 8130-12 (08-2009) Supersedes Previous Edition American LegalNet, Inc. www.FormsWorkFlow.com NSN:0052-00-889-9002
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