Appendix 4 APPE NDIX 4. LIST OF SAMPLE FORMS AND LETTERS IN THIS AC Sample AC Form 8050-1, Aircraft Registration Application (see Appendix 5).
Sample FAA Form 8130-6, Application for Airworthiness Certification (Amateur-Built) (see Appendix 6).
Sample Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing) (see Appendix 8).
Sample AC Form 8050-88, Affidavit of Ownership for Amateur-Built Aircraft (see Appendix 9).
Sample AC Form 8050-2, Aircraft Bill of Sale (see Appendix 10).
Sample letter for requesting an aircraft registration number under 14 CFR § 47.15 (see Appendix 11).
Sample FAA Form 8130-12, Eligibility Statement, Amateur-Built Aircraft (see Appendix 12).
Sample program letter to accompany application for airworthiness certificate (see Appendix 13).
Sample FAA Form 8610-2, Airman Certificate and/or Rating Application (see Appendix 14).
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Appendix 5 APPENDIX 5. SAMPLE AERONAUTICAL CENTER FORM 8050-1,
AIRCRAFT REGISTRATION APPLICATION
FORM APPROVED OMB No. 2120-0042
UNITED STATES OF AMERICA DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION-MIKE MONRONEY AERONAUTICAL CENTER AIRCRAFT REGISTRATION APPLICATION CERT. ISSUE DATE REGISTRATION NUMBER N 130EA UNITED STATES
AIRCRAFT MANUFACTURER & MODEL BUILDER - VANS RV-6 AIRCRAFT SERIAL No.
1001 FOR FAA USE ONLY TYPE OF REGISTRATION (Check one box) K 1. Individual 2. Partnership L 3. Corporation C 4. Co-owner 5. Govt. D 8. Non-Citizen Corporation NAME OF APPLICANT (Person(s) shown on evidence of ownership. If individual, give last name, first name, and middle initial.)
BUILDER, EARLY A.
TELEPHONE NUMBER: ( 903, 555-1212 ADDRESS (Permanent mailing address for first applicant listed.) (If P.O. BOX is used, physical address must also be shown.)
1240 Bois d' Arc Road Number and street: _ Rural Route: P.O. Box:
CITY STATE ZIP CODE SAVOY TX 75479
CHECK HERE IF YOU ARE ONLY REPORTING A CHANGE OF ADDRESS ATTENTION! Read the following statement before signing this application.
A false or dishonest answer to any question in this application may be grounds for punishment by fine and or imprisonment
CERTIFICATION IWE CERTIFY:
(1) Ththe nited Staterat is owned by the undersigned applicant, who is a citizen (including corporations) (For voting trust, give name of trustee: ). or:
CHECK ONE AS APPROPRIATE:
a. C A resident alien, with alien registration (Form 1-151 or Form 1-551) No.
. • A non-citizen corporation organized and doing business under the laws of (state and said aircraft is based and primarily used in the United States. Records or flight hours are available fo inspection at.
(2) That the aircraft is not registered under the laws of any foreign country; and
(3) That legal evidence of ownership is attached or has been filed with the Federal Aviation Administration.
NOTE: If executed for co-ownership all applicants must sign. Use reverse side if necessary.
TYPE OR PRINT NAME BELOW SIGNATURE
SIGNATURE TITLE DATE EACH PART OF THIS APPLICATION MUST IN INK Early A. Builder SIGNATURE TITLE Owner xx/ xx/ xxxx DATE
SIGNES SIGNATURE TITLE DATE VOTE Pending receipt of the Certificate of Aircraft Registration, the aircraft may be operated for a period not in excess of 9 days, during which time the PINK copy of this application must be carried in the aircraft AC Form 8050-1 (5/03) (0052-00-628-9007) 5-1
Appendix 6 APPENDIX 6. SAMPLE FAA FORM 8130-6, APPLICATION FOR
AIRWORTHINESS CERTIFICATE (AMATEUR-BUILT) (FACE SIDE) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 Exp. date: 12/31/2010 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA use U.S. Department Federal Aviation of Transportatio U.S. AIRWORTHINESS CERTIFICATE required, use attachment. For special flight permits complete Sections II, VI and only. Submit original only to an authorized FAA Representative. VIl as applicable If additional space is Administs REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR. | FAA CODING L AIRCRAFT DESIGNATION N130EA Builder VAN'S RV-6 2001
5. AIRCRAFT SERIAL NO. 6. ENGINE BUILDER'S NAME (Alake) 7. ENGINE MODEL DESIGNATION 1001 LY-CON 0-360 EXP
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) ONE SENSENICH C2YK-1BF/F7661B4 IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) A 1 STANDARD AIRWORTHINESS CERTIFICATE (Indicate Calegory) NORMAL UTILITY ACROBATIC TRANSPORT COMNUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate dema
PRIMARY LIGHT-SPORT (Indicate Glasa) AIRPLANE POWER- WEIGH T-CONTROL LIGHTER
LIMITED
CLASS I PROVISIONAL (Indicate Class) IL. CERTIFICATION REQUESTED CLASS II AGRICULTURE AND PEST CONTROL AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate operation(a) to be conducted) FOREST (Wilatife Conservation) 5 PATROLLING WEATHER CONTROL OTHER (Specify) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT EXHIBITION AIR RACING | 5 CREW TRAINING MARKET SURVEY / EXPERIMENTAL (Indicate speration(s) to be conducted) TO SHOW COMPLIANCE WITH THE CFR 7 OPERATING (Primary Category) KIT BUILT AIRCRAFT Existing Aircraft without an airworthiness certificate & da not meet § 103.1 OPERATING LIGHT-SPORT BB ing Light-Sport Kit-Buit ng light-sport previously issued special light sport cafegary
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE
SPECIAL FLIGHT PERMIT EVACUATION FROM AREA OF IMPENDING DANGER peration(s) to be conducted, OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE OFF WEIGHT DELIVERING OR EXPORTING 5 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS C 6 MULTIPLE AIRWORTHINESS CERTIFICATE (check ABOVE * Operation" and "Standard" or Limited" as applicable) A. REGISTERED OWNER (As sho on certificate of aircraft registration) IF DEALER, CHECK HERE Early A. Builder ADDRESS 1240 Bois d'Are Rond, Sarray, TX 75479 B. AIRCRAFT CERTIFICATION BASIS (Check applicable blocka and comple III. OWNER'S CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No. and SOBEY the last AO SUPPLEMENT available in if AIRWORTHINESS DIRECTIVES (C of give the AIRCRAFT LISTING (Give piage number(a)) SUPPLEMENTAL TYPE CERTIFICATE (Lat
IN/A IN/A
AIRCRAFT OPERATION AND MAINTENANCE RECORDS CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Ente Section 91.417 COMPLIANCE WITH 14 CFF 0.0 renewed 0.0 CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 at seg. and applicable Federal A 1 Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested DATE OF APPLICATION NAME AND TITLE (Print or type) pan Early A. Builder 01/30/2009 Early A. Builder, Owner A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183(8) appfet IV. INSPECTION VERIFICATION 2 10e Centican 121 CERTIFICATE HOLDER CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (Give O ate No J AGENCY AIRCRAFT MANUFACTURER (Give name or firm)
DATE TITLE SIGNATURE (Check ALL applic THE CERTIFICATE REQUESTED REPRESENTATIVE CERTIFICATION A I find that the aircraft described in Section I or VIl meets requirements for AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE V. FAA Inspection for a special permit under Section VIl was conducted by: FAA INSPECTOR CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 FAA DESIGNEE DATE DISTRICT OFFICE DESIGNEE'S SIGNATURE AND NO. FAA INSPECTOR'S SIGNATURE FAA Form 8130-6 (10-04) Previous Edition Dated 5/01 May be Used Until Depleted, Except for Light-Sport Aircraft NSN: 0052-00-024-7006 6-1
Appendix 6 APPENDIX 6. SAMPLE FAA FORM 8130-6, APPLICATION FOR
AIRWORTHINESS CERTIFICATE (AMATEUR-BUILT) (REVERSE SIDE)
A MANUFACTURER
NAME ADDRESS VL. PRODUCTION FLIGHT TESTING B. PRODUCTION BASIS (CA PRODUCTION CERTIFICATE (Give produ
TYPE CERTIFICATE ONLY
APPROVED PRODUCTION INSPECTION SYSTEM C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS DATE OF APPLICATION NAME AND TITLE (Prist or Type) SIGNATURE A. DESCRIPTION OF AIRCRAFT
REGISTERED OWNER ADDRESS BUILDER (Make) MODEL
REGISTRATION MARK CUSTOMER DEMONSTRATION FLIGHTS • (Check if appicable) TO
DEPARTURE DATE DURATION C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify)
AIRWORTHINESS R F. CERTIFICATION - I hereby certify that I am the re tered owner (or his agent) of the aircraft described above; that the aircraft is registered with the Federal Aviation Administration i ccordance with Title 49 of the United States Code 44101 ef seg. and applicable Federal Aviation Regulations; and that the aircraft has been inspected and is sale for the fight describe DATE NAME AND TITLE (Print or Type) SIGNATURE DOCUMENTATION (FAA/DESIGNEE Unt A. Operating Limitations and Markings in Compliance with 14 CFR Section 91.9, as applicable. G. Statement of Conformity, FAA Form 8130-g (Attach when required) B. Current Operating Lin itations Attached H. Foreign Airworthiness Certification for Import Aircraft (Attach when required) C. Data, Drawings, Photographs, etc. (Aftach when required) 1. Previous Airworthiness Certificate Issued in Accordance with D. Current Weight and Balance information Available in Aircraft 14 CFR Section _ CAR_ (Driginal Atlached) E. Major Repair and Alteration, FAA Form 337 (Alach when required) J. Current Airworthiness Cerfificate Issued in Accordance wilt 14 CFR Section - _ (Capy Affached) F. This inspection Recorded in Aircraft Records K. Light-Sport Aircraft Statement of Compliance, FAA Form 8130-15 (Attach when required) FAA Form 8130-6 Previous Edition Dated 5/01 May be Used Until Depleted, except for Light-Sport Aircraft NSN: 0052-00-024-7006 6-2
Appendix 7 APPE NDIX 7. USEFUL ADDRESSES Federal Aviation Administration Aircraft Registration Branch, AFS-750 Mailing Address P.O. Box 25504 Oklahoma City, OK 73125-0504 Physical Address 6425 South Denning Registry Building, Room 118 Oklahoma City, OK 73169 Telephone: (405) 954-3116 Fax: (405) 954-3548
Experimental Aircraft Association, Inc.
Mailing Address P.O. Box 3086 Oshkosh, WI 54903-3086 Physical Address 3000 Poberezny Rd.
Oshkosh, WI 54902 Telephone: (920) 426-4800 Fax: (920) 426-6761 EAA aviation information services: (920) 426-4800 E-mail: webmaster@eaa.org Public Web site: http://www.eaa.org Members Only Web site: http://members.eaa.org/homebuilders/index.html 7-1
Appendix 7 7-2 FAA’s Production and Airworthiness Division, National Kit Evaluation Team Production and Airworthiness Division (AIR-200) Federal Aviation Administration 950 L’Enfant Plaza SW.
5th Floor, Suite 500 Washington, DC 20024 ATTN: National Kit Evaluation Team Telephone: (202) 385-6346 Fax: (202) 385-6475
Appendix 8 APPENDIX 8. AMATEUR-BUILT AIRCRAFT FABRICATION AND ASSEMBLY CHECKLIST (2009) (FIXED-WING)
Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing)
NOTE: This checklist is applicable only to fixed-wing aircraft. Evaluation of other types of aircraft (that is, rotorcraft, balloons, lighter than air) will not be accomplished with this form.
Name(s):…………………………………………
Address:………………………………………....
Aircraft Model:………………………………….
Date:……………………………………………..
Remarks:………………………………………… …………………………………………………...
NOTE: This checklist is invalid for and will not be used to evaluate an altered or modified type-certificated aircraft with the intent to issue an Experimental Amateur-Built Airworthiness Certificate. Such action violates FAA policy and DOES NOT meet the intent of 14 CFR § 21.191(g).
Note: Enter “N/A” in any box where a listed task is not applicable to the particular aircraft being evaluated.
Use the “Add item” boxes at the end of each section to add applicable unlisted tasks and award credit.
A B C D FABRIC ATION AND ASSEMBLY TASKS Mfr Kit/Part/ Component Commercial Assistance Am-Builder Assembly Am-Builder Fabrication Task Fuselage — 24 Listed Tasks #
F1 Fabricate Longitudinal Members F2 Fabricate Composite Cores or Shells, Skins F3 Fabricate Bulkheads or Cross-members F4 Fabricate Control Yokes/Sticks F5 Assemble Control Yokes/Sticks F6 Fabricate Flt Control Push Pull Tubes/Cables F7 Assemble Flt Control Push Pull Tubes/Cables F8 Assemble Fuselage Basic Structure F9 Fabricate Brackets and Fittings F10 Assemble Brackets and Fittings F11 Fabricate Cables, Wire, and Lines F12 Assemble Cables, Wire, and Lines page 1 of 11 8-1
Appendix 8 F13 Fabricate Fuselage Fuel System Components F14 Assemble Fuselage Fuel System Components F15 Fabricate Fuselage Covering or Skin F16 Assemble Fuselage Covering or Skin F17 Fabricate Windshield F18 Assemble Windshield to Fuselage F19 Fabricate Windows F20 Assemble Windows to Fuselage F21 Fabricate Doors/Canopy F22 Assemble Doors/Canopy to Fuselage F23 Fabricate Mast and Strut Assembly F24 Assemble Mast and Strut Assembly Add item:
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Total of # Fuselage Tasks
Fuselage Subtotal Mfr Kit/Part/ Component Commercial Assistance Am-Builder Assembly Am-Builder Fabrication Fuselage Total Points ►
A B C D
FABRICATION AND ASSEMBLY TASKS Mfr Kit/Part/ Commercial Am-Builder Am-Builder Component Assistance Assembly Fabrication Task Wings — 51 Listed Tasks # W1 Fabricate Wing Spars W2 Assemble Wing Spars to Wing
W3 Fabricate Wing Ribs or Cores W4 Assemble Wing Ribs or Cores to Wing W5 Fabricate Composite Cores W6 Assemble Composite Cores to Wing W7 Fabricate Wing Leading and Trailing Edges W8 Assemble Wing Leading & Trailing Edges to Wing W9 Fabricate Drag/Anti-drag Truss Members W10 Assemble Drag/Anti-drag Truss Members to Wing W11 Fabricate Wing Brackets and Fittings W12 Assemble Wing Brackets and Fittings to Wing W13 Fabricate Wing Tips W14 Assemble Wing Tips to Wings W15 Fabricate Special Tools or Fixtures W16 Fabricate Aileron Spars W17 Fabricate Aileron Ribs or Cores W18 Assemble Aileron Ribs or Cores to Aileron Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing) page 2 of 11
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Appendix 8 W19 Assemble Aileron Primary Structure W20 Fabricate Aileron Leading and Trailing Edges W21 Assemble Aileron Leading and Trailing Edges W22 Fabricate Aileron Brackets and Fittings W23 Assemble Aileron Brackets & Fittings to Aileron W24 Fabricate Aileron covering or Skin W25 Assemble Aileron Covering or Skin to Aileron W26 Fabricate Aileron Roll Trim W27 Assemble Aileron Trim Tab/Roll Trim to Aileron W28 Assemble Aileron to Wing W29 Fabricate Flap Spars W30 Assemble Flap Spars to Flap W31 Fabricate Flap Ribs or Cores W32 Assemble Flap Ribs or Cores to Flap W33 Assemble Flap Primary Structure W34 Fabricate Flap Leading and Trailing Edges W35 Assemble Flap Brackets and Fittings to Flap W36 Fabricate Flap Covering or Skin W37 Assemble Flap Covering or Skin to flap W38 Assemble Flaps to Wing W39 Fabricate Wing External Lighting Components W40 Assemble Wing Ext Lighting Components to Wing W41 Assemble Basic Wing Structure W42 Fabricate Wing Fuel System components W43 Assemble Wing Fuel System Components to Wing W44 Fabricate Cables Wires and Lines W45 Assemble Cables Wires and Lines to Wing W46 Fabricate Wing Covering or Skin W47 Assemble Wing Covering or Skin to Wing W48 Fabricate Wing Struts/Wires W49 Fabricate Fuel Tank W50 Assemble Fuel Tank to Wing W51 Calibrate Fuel System Components Add item:
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Total # of Wings Tasks Wings Subtotal Mfr Kit/Part/ Component Commercial Assistance Am-Builder Assembly Am-Builder Fabrication Wings Total Points ► Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing) page 3 of 11
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Appendix 8
A B C D FABRICATION AND ASSEMBLY TASKS Mfr Kit/Part/ Commercial Am-Builder Am-Builder Component Assistance Assembly Fabrication Task Empennage — 57 Listed Tasks # E1 Fabricate Horizontal Stabilizer Spars E2 Assemble Horizontal Stabilizer Spars to Stabilizer E3 Fabricate Ribs or Cores E4 Assemble Horizontal Stabilizer Ribs or Cores to Stabilizer E5 Fabricate Horizontal Stabilizer Leading and Trailing Edge E6 Assemble Horizontal Stabilizer Leading and Trailing Edges to Stabilizer E7 Fabricate Horizontal Stabilizer Brackets & Fittings E8 Assemble Horizontal Stabilizer Brackets and Fittings to Stabilizer E9 Assemble Horizontal Stabilizer Structure E10 Fabricate Horizontal Stabilizer Lead/Trailing Edges E11 Assemble Horizontal Stabilizer Lead/Trailing Edges to Stabilizer E12 Fabricate Horizontal Stabilizer Cables, Wires and Lines E13 Assemble Horizontal Stabilizer Cables, Wires and Lines to stabilizer E14 Fabricate Horizontal Stabilizer Empennage Covering or Skin E15 Assemble Horizontal Stabilizer Empennage Covering or Skin to Stabilizer E16 Assemble Horizontal Stabilizer Structure to F uselage E17 Fabricate Elevator Spars E18 Assemble Elevator Spars to Elevator E19 Fabricate Elevator Ribs or Cores E20 Assemble Elevator Ribs or Cores to Elevator E21 Assemble Elevator Structure E22 Fabricate Elevator Leading and Trailing Edge E23 Assemble Elevator Leading and Trailing Edges to Elevator E24 Fabricate Elevator Brackets and Fittings E25 Assemble Elevator Brackets and fittings to Elevator E26 Fabricate Elevator Covering or Skins E27 Assemble Elevator Covering or Skins to Elevator E28 Fabricate Elevator Trim Tab E29 Assemble Elevator Trim Tab to Elevator E30 Fabricate Special Tools or Fixtures Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing) page 4 of 11
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Appendix 8 E31 Fabricate Vertical Stabilizer Spars E32 Assemble Vertical Stabilizer Spar to the Vertical Stabilizer
E33 Fabricate Vertical Stabilizer Ribs or Cores E34 Assemble Ribs or Cores to Vertical Stabilizer E35 Fabricate Vertical Stabilizer Leading/Trailing Edges E36 Assemble Leading and Trailing Edges to Vertical Stabilizer
E37 Fabricate Vertical Stabilizer Brackets and Fittings E38 Assemble brackets and Fittings to Vertical Stabilizer E39 Fabricate Vertical Stabilizer Cables, Wires, Lines E40 Assemble Cables, Wires, Lines to Vertical Stabilizer E41 Fabricate Vertical stabilizer Empennage Covering or Skin
E42 Assemble Vertical stabilizer Empennage Covering or Skin to Vertical Stabilizer
E43 Assemble Vertical Stabilizer Structure to Fuselage E44 Fabricate Rudder Spar E45 Assemble Rudder Spar to Rudder E46 Fabricate Rudder Ribs or Cores E47 Assemble Rudder Ribs or Cores to Rudder E48 Assemble Rudder Structure E49 Fabricate Rudder Leading and Trailing Edge E50 Assemble Rudder Leading and Trailing Edge to Rudder
E51 Fabricate Rudder Brackets and Fittings E52 Assemble Rudder Brackets and Fittings to Rudder E53 Fabricate Rudder Covering or Skin E54 Assemble Rudder Covering or Skin to Rudder E55 Fabricate Rudder Trim Tab E56 Assemble Rudder Trim Tab to Rudder E57 Assemble Rudder to Vertical Stabilizer Add item:
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Total # of Empennage Tasks Empennage Subtotal Mfr Kit/Part/ Component Commercial Assistance Am-Builder Assembly Am-Builder Fabrication Empennage Total Points ► Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing) page 5 of 11
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Appendix 8
A B C D FABRICATION AND ASSEMBLY TASKS Mfr Kit/Part/ Commercial Am-Builder Am-Builder Component Assistance Assembly Fabrication Task Landing Gear — 12 Listed Tasks # LG1 Fabricate Struts LG2 Fabricate Brake S ystem Components LG3 Fabricate Lan ding Gear Actuation System Components LG4 Fabricate Lan ding Gear System Cables, Wires and Lines LG5 Assemble Wheels LG6 Asse mble Brakes, Tires LG7 Assemble Landing Gear LG8 Assemble Landing Gear System Components Next Level Structure LG9 Align Landing Gear LG10 Fabricate Landing Gear Fairings/Gear Doors LG11 Assemble Landing Gear Fairings/Gear Doors to Next Level Structure LG12 Perform Landing Gear Op erational Check (Normal, Emergency Systems) Add item:
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Total # of Mfr Kit/Part/ Commercial Am-Builder Am-Builder Land Gear Landing Gear Subtotal Component Assistance Assembly Fabrication Tasks Landing Gear Total Points ► Amateur-Built Aircraft Fabrication and Assembly Checklist (2009) (Fixed-wing) page 6 of 11
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