Free MAJOR REPAIR & ALTERATION (AIRFRAME, POWERPLANT, PROPELLER, OR APPLIANCE) - Federal

US Department of Transportation Federal Aviation Administration

MAJOR REPAIR AND ALTERATION (Airframe, Powerplant, Propeller, or Appliance)

Form Approved OMB No. 2120-0020 2/28/2011

Electronic Tracking Number For FAA Use Only

INSTRUCTIONS: Print or type all entries. See Title 14 CFR §43.9, Part 43 Appendix B, and AC 43.9-1 (or subsequent revision thereof) for instructions and disposition of this form. This report is required by law (49 U.S.C. §44701). Failure to report can result in a civil penalty for each such violation. (49 U.S.C. §46301(a)) Nationality and Registration Mark 1. Aircraft Make Name (As shown on registration certificate) 2. Owner Serial No. Model Series

Address (As shown on registration certificate)
Address City Zip Country State

3. For FAA Use Only

4. Type Repair Alteration Unit AIRFRAME POWERPLANT PROPELLER
Type

5. Unit Identification Make Model (As described in Item 1 above) Serial No.

APPLIANCE

Manufacturer

A. Agency's Name and Address
Name Address City Zip Country State

6. Conformity Statement B. Kind of Agency
U. S. Certificated Mechanic Foreign Certificated Mechanic Certificated Repair Station Certificated Maintenance Organization Manufacturer

C. Certificate No.

D. I certify that the repair and/or alteration made to the unit(s) identified in item 5 above and described on the reverse or attachments hereto have been made in accordance with the requirements of Part 43 of the U.S. Federal Aviation Regulations and that the information furnished herein is true and correct to the best of my knowledge. Extended range fuel per 14 CFR Part 43 App. B Signature/Date of Authorized Individual

7. Approval for Return to Service Pursuant to the authority given persons specified below, the unit identified in item 5 was inspected in the manner prescribed by the Administrator of the Federal Aviation Administration and is Approved Rejected FAA Flt. Standards Inspector FAA Designee Certificate or Designation No. FAA Form 337 (10-06) Manufacturer Repair Station Maintenance Organization Inspection Authorization
Persons Approved by Canadian Department of Transport

BY

Other (Specify)

Signature/Date of Authorized Individual

NOTICE
Weight and balance or operating limitation changes shall be entered in the appropriate aircraft record. An alteration must be compatible with all previous alterations to assure continued conformity with the applicable airworthiness requirements.
8. Description of Work Accomplished (If more space is required, attach additional sheets. Identify with aircraft nationality and registration mark and date work completed.)

Nationality and Registration Mark

Date

Additional Sheets Are Attached FAA Form 337 (10-06)

Paperwork Reduction Act Statement: The reason for collecting this information is to track major maintenance performed on aircraft. The collected information is used as part of the aircraft's historical file. The public reporting burden for this collection of information is estimated to average 30 minutes per response. Responses are mandated by 14 CFR Part 43. Collected information becomes part of the public record and no confidentiality is required. 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 is 2120-0020. 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.