Free Applicant Name - Kansas

Addition to Exemption KSA 79-201k & 79-220 Page 1 of 1

Applicant Name: ________________________ Docket No. _____________________________

Addition to Exemption Application Aircraft K.S.A. 79-201k and K.S.A. 79-220
1. 2. 3. Describe the aircraft (Year, Make, Model, etc.): _____________________________________ Enclose a copy of the FAA Certificate of Aircraft Registration. Enclose a copy of the pilot's log for the preceding year for the subject aircraft. The log should provide a detailed account of how the plane is used for business or personal use. Business Aircraft (K.S.A. 79-201k) Are you in the business of leasing the subject aircraft? _____Yes _____No If "No": a) Provide a detailed description of how the subject aircraft is used in your business and the percentage of time it is used for business purposes. ____________________________________________________________________________ ____________________________________________________________________________ 5. Antique Aircraft (K.S.A. 79-220) a) Provide a detailed description of how the subject aircraft is used. ____________________________________________________________________________ ____________________________________________________________________________

4.

VERIFICATION I, ________________________________, do solemnly swear or affirm that the information set forth herein is true and correct, to the best of my knowledge and belief. So help me God. _________________________________________ Signature of Applicant _________________________________________ Printed Name and Title State of ____________________ County of __________________ ) )

This instrument was acknowledged before me on ______________ by __________________________________.

Seal My appointment expires: ________________

________________________________________ Signature of Notary Public

Revised 5/07