Appendix 2 APPENDIX 2. PREPARATION INSTRUCTIONS FOR FAA FORM 8130-12, ELIGIBILITY STATEMENT
AMATEUR-BUILT AIRCRAFT
1. PURPOSE. This appendix provides instructions for completing FAA Form 8130-12.
A sample form is included as figure 1.
2. GUIDANCE. This form is required to be submitted by a person applying for a special airworthiness certificate, experimental, for the purpose of operating an amateur-built aircraft under section 21.191(g). Prepare the form by inserting in:
a. SECTION I. REGISTERED OWNER INFORMATION: Enter the name, address, and telephone number for residence and place of business.
b. SECTION II. AIRCRAFT INFORMATION: Enter the model (number and/or name), assigned serial number, registration number, whether aircraft was fabricated from a plan or kit, engine make, engine serial number, prop/rotor make, prop/rotor serial number.
c. SECTION III. MAJOR PORTION ELIGIBILITY STATEMENT OF APPLICANT:
The name of person(s) (printed), identified in Section I that certify the aircraft identified in Section II on the form was fabricated and assembled for their own education or recreation. The applicant should sign (in ink), and enter the date signed.
d. SECTION IV. NOTARIZATION STATEMENT: The signature, date, and stamp (if applicable), of a Notary Public who witnessed the signature of the applicant.
Appendix 2 APPENDIX 2. SAMPLE FAA FORM 8130-12, ELIGIBILITY
STATEMENT AMATEUR-BUILT AIRCRAFT Form Approved O.M.B. NO. 2120-0018 ELIGIBILITY STATEMENT Instructions: Print or type all information except signature. Submit original to an authorized FAA representative. Applicant complete of transometion AMATEUR-BUILT AIRCRAFT Section I thru III. Notary Public Completes Section I Federal Aviation
1. REGISTERED OWNER INFORMATION Name(s) Address(es) No & Sirees Cily Telephone No. (s) _ Residence Business II. AIRCRAFT INFORMATION Model Engine(s) Make Assigned Serial No. Engine(s) Serial No.(s) Registration No. Prop./Rotor(s) Make Aircraft Fabricated: Plan Kit O Prop./Rotor(s) Serial No.(s) III. MAJOR PORTION ELIGIBILITY STATMENT OF APPLICANT I certify the aircraft identified in Section Il above was fabricated and assembled by.
for my (their) education or recreation. I (we) have records to support this statement and will make them available to the FAA upon request.
- 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 of 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 (4-89) 2