Free Sample Form 8130-15 Light-Sport Aircraft Statement of Compliance - Federal

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SAMPLE FORM 8130-15, LIGHT-SPORT AIRCRAFT STATEMENT OF COMPLIANCE
Form Approved O.M.B. No. 2120-0690

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, use an attachment.

I. Aircraft Identification

1. Manufacturer Name The ACME Company

2. Manufacturer Address (street, city, zip) 420 W Jackson, Mexico MO 65265 6. Aircraft Model Flyer I 10. VS1 45 KCAS Lighter-Than-Air Valid Until N/A

3. Aircraft Serial No. 4. Date of Manufacture (MM dd, yyyy) 5. Aircraft Make 00002 09/02/2005 ACME 7. Maximum Take-off Weight 8. Maximum Number Occupants 9. VH 1,430 lb 2 120 KCAS Class of light-sport aircraft: (Check all applicable items) X Operation on Water X Airplane Powered Parachute Weight-Shift-Control Glider Revision Consensus Standard(s) (list below or use attachment) N/A ASTM Standard F2245-04 (design and performance) ASTM Standard F2339-04 (engine) ASTM Standard F2316-054 (airframe emergency parachute)

II. Applicable User Manuals III. Manufacturer's Process Documents

Aircraft Operating Instructions (list applicable items) Revision Date issued st ACME-AOI-1 Edition None 08/01/2005 ASTM Standard F2245-04 Revision N/A Date N/A Aircraft Maintenance and Inspection Procedures (list applicable items) Revision Date issued ACME-MM-1st Edition Rev A 08/15/2005 ASTM Standard F2483-05 Revision N/A Date N/A Aircraft Flight Training Supplement (list applicable items) Revision Date issued ACME-FTSupp None 08/01/2005 ASTM Standard F2245-04 Revision N/A Date N/A Comments (any additional statements may be stated here or attached) This aircraft flight test is recorded in the aircraft records per 14 CFR section 91.417, and an airframe time of 5 hours is attributed to flight testing. All applicable service directives to date have been incorporated and annotated in the aircraft records. Manufacturer's Quality Assurance System (list applicable items) ACME-QCS.001 ASTM Standard F2279-03 Manufacturer's Continued Airworthiness System (list applicable items) ACME-CAW.002 ASTM Standard F2295-03 Revision Rev C Revision N/A Revision Rev A Revision N/A Date 07/23/2005

Date 10/31/2004

IV. Manufacturer's Certification

CERTIFICATION: I hereby certify that aircraft serial number -00002 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: Irving M. Himm Title: President, General Manager Name: Title: Date Signature:

I M Himm
Date 9/7/2005

FAA Form 8130-15 (09-04)

SAMPLE FORM 8130-15, LIGHT-SPORT KIT
AIRCRAFT STATEMENT OF COMPLIANCE

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, use an attachment.

I. Aircraft Identification

1. Manufacturer Name Express Aircraft

2. Manufacturer Address (street, city, zip) 1876 N. Parkview Drive, Chandler, OK 65432 6. Aircraft Model Silver One 10. VS1 45 KCAS Lighter-Than-Air Valid Until N/A N/A

3. Aircraft Serial No. 4. Date of Manufacture (MM dd, yyyy) 5. Aircraft Make K-00014 Kit ­ 03/07/2006 Express Flyer 7. Maximum Take-off Weight 8. Maximum Number Occupants 9. VH 1,320 lb 2 120 KCAS Class of light-sport aircraft: (Check all applicable items) Operation on Water X Airplane Powered Parachute Weight-Shift-Control Glider Revision Consensus Standard(s) (list below or use attachment) Rev A Silver One Assembly Instructions, KFSO-1A N/A ASTM Standard F1234-06 (assembly instructions)

II. Applicable User Manuals III. Manufacturer's Process Documents

Aircraft Operating Instructions (list applicable items) Revision Date issued Silver One Operating Instructions, SO-OI-1 None 12/11/2005 ASTM Standard F2245-04 Revision N/A Date N/A Aircraft Maintenance and Inspection Procedures (list applicable items) Revision Date issued Silver One Maintenance Manual, SO-MM-1 Rev A 11/30/2005 ASTM Standard F2483-05 Revision N/A Date N/A Aircraft Flight Training Supplement (list applicable items) Revision Date issued Silver One Flight Training, SO-FT-1 None 12/11/2005 ASTM Standard F2245-04 Revision N/A Date N/A Comments (any additional statements may be stated here or attached) Express Aircraft manufactured and assembled Express Flyer Silver One, serial number F-0002, N456EF, which was issued a special airworthiness certificate in the light-sport category on 12/01/2005. Manufacturer's Quality Assurance System (list applicable items) Express Aircraft QA Manual ASTM Standard F2279-03 Manufacturer's Continued Airworthiness System (list applicable items) N/A Revision Rev C Revision N/A Revision Revision Date 01/18/2006

Date

IV. Manufacturer's Certification

CERTIFICATION: I hereby certify that aircraft kit serial number K-00014 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: Jacob Small Title: General Manager Name: Title: Date Signature:

Jake Small
Date 03/07/2006