Free Eligibility Statement Amateur-Built Aircraft - Federal

Form Approved
OMB NO. 2120-0018
09/30/2007

Instructions: Print or type all information except signature.
US Department of Transportation Federal Aviation Administration

ELIGIBILITY STATEMENT AMATEUR-BUILT AIRCRAFT

Submit original to an authorized FAA representative. Applicant completes Section I thru Ill. Notary Public Completes Section IV.

I. REGISTERED OWNER INFORMATION Name(s) Address(es)
No. & Street City State Zip

Telephone No.(s)
Residence Business

II. AIRCRAFT INFORMATION 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) Ill. MAJOR PORTION ELIGIBILITY STATEMENT OF APPLICANT

I certify by

the

aircraft

identified in Section

II

above

was

fabricate

and

assembled

Name of Person(s)(Please Print)

for my (their) education or recreation. I (we) have records to support this statement make them available to the FAA upon request.

and

will

-NOTICE-

Whoever in any matter within the jurisdiction of any department or agency 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 false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 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 or 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 (4-03) Supersedes Previous Edition

NSN:0052-00-889-9002

ELIGIBILITY STATEMENT AMATEUR-BUILT AIRCRAFT

U.S. Department of Transportation Federal Aviation Administration Privacy Act Statement

Supplemental Information and Instruction

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 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 an 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 Indpendence Ave. SW Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20.

Tear off this cover sheet before submitting this form.


FAA Form 8130-12 (4-03) Supersedes Previous Edition

NSN:0052-00-889-9002