Free Light-Sport Aircraft Statement of Compliance - Federal

INFORMATION FOR APPLICANT
U.S. Department of Transportation Federal Aviation Administration

LIGHT-SPORT AIRCRAFT STATEMENT OF COMPLIANCE
Paperwork Reduction Act Statement: This information is collected for the FAA to review prior to issuance of a special airworthiness certificate for the light-sport aircraft. The manufacturer provides this record of information as evidence that the light-sport aircraft meets the established criteria and was manufactured to an accepted consensus standard. The FAA uses the information to verify the manufacturer's certification statement that the aircraft was manufactured to an accepted consensus standard. This information is mandatory and is required to be signed and maintained by the manufacturer. The burden associated with completing FAA Form 8130-15 is approximately 20 minutes. This information becomes part of the Aircraft Registry and published routine uses of that system apply. 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 control number associated with this collection of information is 2120-0690. 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, ABA-20 .

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FAA Form 8130-15 (09-04)

Form Approved O.M.B. No. 2120-0690 07/31/2007

U.S. Department of Transportation Federal Aviation Administration

Light-Sport Aircraft Statement of Compliance

INSTRUCTIONS ­ Print or type. Present original to an authorized FAA Representative. If additional space is required, us an attachment. 2. Manufacturer Address (street, city, zip)

1. Manufacturer Name
I. Aircraft Identification

3. Aircraft Serial No.

4. Date of Manufacture (mm, dd, yy)

5. Aircraft Make

6. Aircraft Model

7. Maximum Take-off Weight

8. Maximum Number Occupants

9. VH

10. VS1

Class of light-sport aircraft: (Check all applicable items) Airplane Powered Parachute Consensus Standard(s) (list below or use attachment)

Operation on Water Weight-Shift Control Glider
Revision

Lighter Than Air
Valid Until

II. Applicable User Manuals

Aircraft Operating Instructions (list applicable items) Consensus Standard: Aircraft Maintenance and Inspection Procedures (list applicable items) Consensus Standard: Aircraft Flight Training Supplement (list applicable items) Consensus Standard: Comments (any additional statements may be stated here or attached)


Revision

Date issued

Revision Revision

Date Date issued

Revision Revision

Date Date issued

Revision

Date


III. Manufacturer's Process Documents

Manufacturer's Quality Assurance System (list applicable items) Consensus Standard: Manufacturer's Continued Airworthiness System (list applicable items) Consensus Standard:

Revision

Date

Revision Revision

Date

Revision

IV. Manufacturer's Certification

CERTIFICATION: I hereby certify that aircraft serial number complies with the Consensus Standard(s) identified on this statement of compliance and that the Manufacturer's Continued Airworthiness System will be adhered to support the aircraft throughout its life. This aircraft (1) was manufactured following the consensus standard(s) procedures and Manufacturer's Quality Assurance System identified on this statement, (2) conforms to the manufacturer's design data, (3) was ground and flight tested successfully, and (4) is in a condition for safe operation. Additionally, at the request of the FAA, the manufacturer will provide unrestricted access to its facilities.
Name: Title: Name: Title: Date Signature: Date

FAA Form 8130-15 (09-04)