AC 21-40A

Appendix 1 APPENDIX 1. FAA FORM 8110-12, APPLI CATION FOR TYPE CERTIFICATE,

PRODUCTION CERTIFICATE, OR SUPPLEMENTAL TYPE CERTIFICATE Complete one copy of FAA Form 8110-12 as follows (see sample form at the end of this appendix):

Item 1. Enter the name and address of the party, corporation or organization to whom the STC will be issued. The name will app ear on the certificate exactly as it is entered here. Note: A post office box will not be accepted.

Item 2. Check the block for “Supplemental Type Certificate.”

Item 3. Check the product involved (aircraft, engine, or propeller).

Note: Aircraft models having different TCs will require separate substantiations for each aircraft on th e Approved Model List (AML). For 14 CFR part 23 airplanes in particular, how to create and use an AML is discussed in Advisory Circular AC 23-22, Guidance for Approved Model List (AML) Supplemental Type Certific ated (STC) Approval of Part 23 Airplane Avionics Installations . But note that although AML STCs are predominantly issued to 14 CFR part 23 airplanes, they are not limited to that type of product. Consult with your local ACO to see if AML is appropriate for your proposed change.

Items 4 and 5. Leave it blank for STCs.

Item 6.

a. List the manufacturer of the aircraft, engine, or propeller and the specific models to be included as shown by the identifica tion plates. These designations are also listed in the applicable specification, or data sheet, which may be examined at local FAA offices. Popular names such as “Cub,” “Skylane,” etc. should not be used. If the STC is utilizing a Proposed AML effectivity, insert a statement that states: “See attached Proposed AML for make and model effectivity”.

Note: If the requested approval is for a “one-only” aircraft, engine, or propeller, the applicant should indicate the applicable serial number. This data should be in 6b .

b. Use this space for a brief narrative description of the change. Include descriptive data such as installation instructions and/ or drawing lists if they are available at the time of application and the effected airplanes serial number. (See sample form).

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Appendix 1

c. 1. Answer “No” if descriptive data and parts will not be made available to others. Descriptive data must completely describe the change, but may consist of marked photographs, sketches, and word descriptions. Detailed installation instructions are not required for a “one-only” installation intended for one specific aircraft.

2. Answer “Yes” if descriptive data and parts are to be made available to others. Installation instructions and good quality descriptive data, with sufficient detail to ensure repeatability, are required for duplicate parts and installations.

d. 1. Answer “No” if descriptive data w ill be made available, but parts will not be supplied. Data requirements are the same as for 6.c.2.

2. Answer “Yes” if installation instructions and parts will be made available.

Installation instructions are require d which will permit duplication of the installation to the standards required for certification.

Note: When 6.d.2. is answered “Yes” and the STC has been approved, compliance with 14 CFR § 21.303 will be required as evidence of inspection approval of manufactured parts.

Item 7. The application should be dated and signed by the applicant or authorized agent as the certifying official. The certifying official must be the holder or the person duly authorized to sign for the holder, co mpany, or corporation. Upon receipt of the application and certification plan, an FAA project number will be assigned and the applicant notified of this ac tion. All subsequent submittals and correspondence should reference this project number.

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09/27/07 AC 21-40A Appendix 1 Sample STC Application No certificate may be issued unless a completed application form has been received (14 C.F.R.-21) U.S. DEPARTMENT OF TRANSPORTATION

FEDERAL AVIATION ADMINISTRATION FORM APPROVED APPLICATION FOR TYPE CERTIFICATE, PRODUCTION CERTIFICATE, OR O.M.B. No. 2120-0018

SUPPLEMENTAL TYPE CERTIFICATE

1. Name and address of applicant 2. Application made for - 3. Product Involved … Type Certificate ⌧ Aircraft Acme Aircraft Corporation … Production Certificate … Engine ⌧ Supplemental Type … Propeller 123 Noname St. Certificate Nowhere, Kansas 71953

4. TYPE CERTIFICATE (Complete item 4a below)

a. Model designation(s) (All models listed are to be completely described in the required technical data, including drawings representing the design, material, specifications, construction, and performance of the aircraft, aircraft engine, propeller which is the subject of this application.)

LEAVE BLANK FOR STC APPLICATION

5. PRODUCTION CERTIFICATE (Complete items 5a-c below. Submit with this form, in manual form, one copy of quality control data or changes thereto covering new products, as required by applicable FAR.)

a. Factory address ( if different from above) b. Application is for - P.C. No.

… New production certificate … Additions to production LEAVE BLANK FOR Certificate (Give P.C. No.)

STC APPLICATION

c. Applicant is holder of or a licensee under a Type Cert ificate or a Supplemental Type Certificate T.C./S.T.C. No.

(Attach evidence of licensing agreement and give certificate number) __________________________>

6. SUPPLEMENTAL TYPE CERTIFICATE ( Complete items 6a-d below)

a. Make and model designation of product to be modified Schtickenrudder P-48, P-48A, P-48B

b. Description of modification Install wing flap hinge bracket (P/N 60000) in accordance with Acme drawing list 60DL, Rev. N/C, dated 01/25/88

c. Will data be available for sale or release to other persons? d. Will parts be manufactured for sale? (Ref. FAR 21.303) ⌧ YES … NO ⌧ Yes … NO

7. CERTIFICATION - I Certify t at the above statements are true.h Signature of certifying official Title Date General Manager 02/01/88 FAA Form 8110-12 (4-03) SUPERSEDES PREVIOUS EDITION (REPRESENTATION) A-3

09/27/07 AC 21-40A Appendix 1 U.S. Department of Transportation

INFORMATION FOR APPLICANT Federal Aviation Administration

APPLICATION FOR TYPE CERTIFICATE, PRODUCTION CERTIFICATE,

OR SUPPLEMENTAL TYPE CERTIFICATE Paperwork Reduction Act Statement:

This collection of information is for the purpose of issuing a U.S. Type Certificate, Production Certificate, or Supplemental Type Certificate to any applicant meeting the criteria established in 14 CFR part 21. The FAA uses the information to evaluate an applicant’s application for a U.S. Type Certificate, Production Certificate, or Supplemental Type Certificate. The information on FAA Form 8110- 12, Application for Type Certificate, Production Certificate, or Supplemental Type Certificate is solicited under the authority of 49 U.S.C. 44702 as implemented by 14 CFR part 21. The burden associated with completing FAA Form 8110-12 is 48 minutes. Providing this information is mandatory if an applicant wishes to obtain a Type Certificate, Production Certificate, or Supplemental Type Certificate.

Confidentiality is neither provided nor necessary. 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 of information is 2120-0018.

Tear off this cover sheet before submitting this form.

FAA Form 8110-12(4-03) Supersedes Previous Edition (Representation) A-4

Appendix 2 APPENDIX 2. SAMPLE DRAWING PACKAGE This appendix includes a two-page sample drawing list and three sample drawings (sample installation drawing, assembly/subassembly drawing, and part fabrication detail drawing) for installing the Acme Aircraft Corporation flap hinge bracket installation.

Acme Aircraft Corporation Drawing List 60DL Flap Hinge Bracket Installation (P-48 Series) Revision Control Page Page 1 of 2 Revision Date Page Nos. Affected Approved N/C A 01/02/88 01/25/88 1, 2 1, 2 (approval signature) (approval signature) Company Approved: (approval signature) Date: 01/25/88 Acme Aircraft Corporation Drawing List 60DL Flap Hinge Bracket Installation (P-48 Series) Page 2 of 2 Document Number Title Rev. Date Installation Data 60-II 60000 Installation Instructions P-48 Series Flap Hinge Bracket Flap Hinge Brackets Installation A A 07/05/87 02/22/87 Manufacturing Data 60100 Flap Hinge Bracket Assy.

60101 Wing Flap Hinge Bracket y y AAC41 Epoxy Specification AAC60 Inspection Procedures A B N/C N/C 01/25/88 01/25/88 04/19/86 01/02/88 Company Approved: (approval signature) Date: 01/25/88 A-5

' ~

09/27/07 AC 21-40A Appendix 2 Sample Installation Drawing NOTES:

1. JIG ALIGN HINGE BRACKETS PRIOR TO MARKING AND DRILLING SPAR

2. THIS INSTALLATION APPLICABLE TO SCHTICKENRUDDER MODELS P-48, P-48A, P-48B PER STC #SA 70000 NP

3. LEFT WING INSTALLATION SHOWN

RIGHT WING OPPOSITE

4. DRAWING NOT TO SCALE STA STA STA

76.5 41.5 6.5

REVISIONS CHG. LET. CHANGES BY DATE A ADDED NOTES 3 & 4 JOE 2/22/87 WING STA.

0.0

HINGE ATOP VIEW - LEFT WING 60100 BRACKET DETAIL A (TYP 3 PLACES)

1.50

CL SPAR MATCH DRILL SPAR WITH PN 60100 REAR SPAR 12 12 NO REQ 3 24 AN365-428 AN4-6A 60100 PART NO.

AN960-10

SIZE DISCRIPTION BOLT WASHER BRACKET ASS’YS NUT SPEC.

BOX 1 NOWHERE, AR ACME

AIRCRAFT CORP

INSTALLATION

HINGE BRACKETS FLAPS 60000 A FIN: TOL. XX+/- .03, XXX+/- .010 X = +/- 1 OR NOTED DRW. M.S 1/20/87 CHK. SM 1/21/87 APP’D J.K. 1/22/87 ~ ~ ~ ~ ~ ~ ~ ~ .257 +/- .005 DIA 4 PLACES EACH BRACKET AN4-6A BOLT, 12 REQ’D AN960-10 WASHER, 24 REQ’D AN365-428NUT,12 REQ’D.

Sample Assembly/Subassembly Drawing NOTES:

1. MASK OUT BEARING PRIOR TO FINISH OPERATION

2. SCALE ~ FULL SIZE

MATCH DRILL #30, 7 PLACES, AN470AD4-5 RIVET 7 REQ’D.

60101 BRACKET (2 REQ.)

SECTION A-A

REVISIONS

CHANGES #30 HOLE WAS #11 BY DATE CHG. LET.

A 1/25/87 M.S.

7 NO REQ 2 1 AN4-70 60101 PART NO.

N4-B

SIZE DESCRIPTION RIVET

BEARING-HEIM

BRACKET SPEC.

BOX 1 NOWHERE, AR ACME

AIRCRAFT CORP

ASSEMBLY

HINGE BRACKET FLAP 60100 A FIN: VINYL WASH TOL.. XX+/- .03, XXX+/- .010 X = +/- 1 OR NOTED DRW. M.S 1/11/87 CHK. SM 1/21/87 APP SAM 1/17/87 AD4-5

COMMERCIAL A A .50 (TYP) PRESS FIT N4B BEARING, STAKE 4 PLACES EQUALLY

SPACED, BOTH SIDES .25 (TYP) .50 (TYP) A-6

ACME

AIRCRAFT CORP Appendix 2 Sample Part Fabrication Detail Drawing NOTES:

1. ALT MAT’L THICKNESS .063

2. ALT FIN. EPOXY PER SPEC. AAC 4-1

3. SCALE: FULL SIZE L SYM C

1.50 .75

2.25 LCLC .50 RAD.

+ .005

- 000

.500 DIA

HOLE

2.25

1.75

REVISIONS CHG. LET. CHANGES BY DATE A MAT’L WAS AL 30 . FIN. WAS ZINC B

ADDED ZINC CHROMATE IN FIN.

BLOCK SAM 1/25/88 .25 RAD.

+.005

- 000 .250 DIA. HOLE (2 PLACES) .38

1.00

1 - 1 .050 X 3.07 X 1.0 2024-T3 AL. SHT. QQ-A-250/4 NO REQ PART NO. SIZE DESCRIPTION SPEC ACME

AIRCRAFT CORP BOX 1 NOWHERE, ARK.

BRACKET

FLAP HINGE WING 60101 B FIN: VINYL WASH TOL.. XX+/- .03, XXX+/- .010 X = +/- 1 OR NOTED DRW. M.S 11/10/87 CHK. S.M. 11/12/87 APP’R. J.K. 1/2/88 A-7

_______________________________________________________ _______________________________________________________ Appendix 3 APPENDIX 3. SAMPLE SUPPLEMENTAL TYPE CERTIFICATE United States Of America

Department of Transportation - Federal Aviation Administration

Supplemental Type Certificate Number ST00001DC This Certificate issued to U.S. Cargo Conversion Company 5201 Tranquility Lane Colorful, Colorado 80110

certifies that the change in the type design for the following product with the limitations and conditions therefore as specified hereon meets the airworthiness requirements of Part 25* of the Federal Aviation Regulations.

Original Product Type Certificate Number: A16WE Make: The Boeing Company * SEE PAGE 3 737-300 Series Model:

Description of Type Design Change: Conversion of a Boeing 737-300 passenger configuration to freighter configuration (including full cargo floor, main deck cargo door, interior and associated systems) in accordance with PCCC Master Drawing List PC-001, Revision B, dated March 23, 2001, or later FAA-approved revisions.

Limitations and Conditions: The installation should not be incorporated in any aircraft unless it is determined that the interrelationship between this installation and any previously approved configuration will not introduce any adverse effect upon the airworthiness of the aircraft.

(Limitations and Conditions continued on page 3 of 4) This certificate and the supporting data which are the bases for approval shall remain in effect until surrendered, suspended, revoked, or a termination date is otherwise established by the Administrator of the Federal Aviation Administration.

Date reissued: Date of application: March 20, 2001 Date amended:

Date of issuance: April 24, 2002 By direction of the Administrator (Signature) Manager, Aircraft Certification Office (Title) Any alteration of this certificate is punishable by a fine of not exceeding $1,000, or imprisonment not exceeding 3 years, or both .

FAA Form 8110-2 (10-68) Page 1 of 3 This certificate may be transferred in accordance with FAR 21. 47.

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_____________________________________________________________________________________________________________________________________ Appendix 3 FAA Form 8110-2.1: SAMPLE DOCUMEN TING A CERTIFICATION BASIS United States Of America

Department of Transportation - Federal Aviation Administration

Supplemental Type Certificate (Continuation Sheet) Number ST00001DC Instructions for Continued Airworthiness (ICA), U.S. Cargo Conversion Company Document No. 123, Rev. A, dated 9/08/1988, or later FAA accepted revision must be made available to the operator at the time of installation.

Certification Basis:

Based on 14 CFR §§ 21.115 and 21.101, and the FAA policy for significant changes in FAA Order 8110.48, the certification basis for the Boeing Model 737-300 series passenger to Freighter is as follows:

a. The type certification basis for Boeing Model 737 series airplanes is shown on TCDS A16WE for parts not changed or not affected by the change.

b. The certification basis for parts changed or affected by the change since the reference date of application, March 20, 2001, is based upon part 25 as amended by Amendment 25-101. Based on 14 CFR §§ 21.115 and 21.101, and the FAA policy for significant changes in FAA Order 8110.48, the certification basis for this modification was determined to be:

Regulations at the latest amendment 25-0 through 25-101

25.1 - 25.31, 25.301 - 25.307, 25.561 - 25.563, 25.581, 25.601 - 25.625, 25.671 - 25.689, 25.729,

25.777, 25.783 - 25.793, 25.801 – 25.812, 25.843, 25.851 - 25.869, 25.871, 25.903, 25.1301,

25.1309, 25.1322 – 25.1326, 25.1351 – 25.1363, 25.1411 – 25.1423, 5.1431 – 25.1461, 25.1501,

25.1519 – 25.1533, 25.1541 – 25.1563, 25.1581 – 25.1585, Appendix F Regulations at an intermediate amendment

25.574 Amendment 25-54

25.629 Amendment 25-46 Appendix H Amendment 25-54 Regulations at the amendment level in TCDS A16WE

25.25, 25.321 - 25.373, 25.471 - 25.519, 25.731 – 25.735, Appendix G If the holder agrees to permit another person to use this certificate to alter the product, the holder shall give the other person written evidence of that permission. More on Continuation page #2.

----------------------------------------END---------------------------------------- Any alteration of this certificate is punishable by a fine of not exceeding $1,000, or imprisonment not exceed ing 3 years, or both.

FAA Form 8110-2(10-68) Page 2 of 3This certificate may be transferred in accordance with FAR 21.47.

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Appendix 3

SAMPLE SUPPLEMENTAL TYPE CERTIFICATE FAA Form 8110-2.1. SAMPLE DOCUMEN TING A CERTIFICATION BASIS (CONTINUED) The type design of the Windjet 100 series airplanes was approved by issuing Type Certificate A11DC.

The Windjet 100 series airplanes were certified to amendment 22 of 14 CFR part 25. In June 2000, the TC was amended to include the Windjet 100AC. The Windjet 100AC is a retrofit of a Windjet 100 airplane with an Advanced Cockpit (AC). The following is based on information from the Windjet 100 Type Certificate Data Sheet (TCDS):

1. For all Model Windjet 100AC airplanes, issuance of a TC is based on compliance with the following:

a. Conversion of a Windjet 100 to a Windjet 100AC can be accomplished by Windjet Aircraft Drawing SP10000.

b. The Certification Basis is defined as:

(1) Title 14 CFR part 25, dated February 1, 1965, with Amendments 1 through 22 “Airworthiness Standards: Transport Category Airplanes,” and 14 CFR § 25.471 of Amendment 25-23, for all areas not affected by the change.

(2) Title 14 CFR part 25, dated February 1, 1965, including Amendments 25-1 through 25-89 for the change and all areas affected by the change. The following lists the Federal Aviation Regulations complied with through Amendment Level 25-89.

25. 125 25. 605 25. 685 25. 841 25. 1039 25. 1326 25. 1435 25. 1541

25. 145 25. 607 25. 689 25. 843 25. 1141 25. 1327 25. 1439 25. 1543

25. 149 25. 609 25. 693 25. 855 25. 1142 25. 1329 25. 1441 25. 1545

25. 207 25. 611 25. 699 25. 857 25. 1145 25. 1331 25. 1443 25. 1549

25. 301 25. 613 25. 703 25. 858 25. 1161 25. 1333 25. 1445 25. 1551

25. 303 25. 615 25. 729 25. 863 25. 1165 25. 1335 25. 1447 25. 1553

25. 305 25. 619 25. 733 25. 901 25. 1207 25. 1337 25. 1449 25. 1555

25. 307 25. 621 25. 771 25. 903 25. 1301 25. 1351 25. 1451 25. 1563

25. 397 25. 623 25. 773 25. 943 25. 1303 25. 1353 25. 1453 25. 1581

25. 399 25. 625 25. 777 25. 952 25. 1305 25. 1355 25. 1457 25. 1583

25. 405 25. 629 25. 779 25. 954 25. 1307 25. 1357 25. 1459 25. 1585 A-10

rJ D D D D D D D D D

09/27/07 AC 21-40A Appendix 4 APPENDIX 4. GUIDE FOR PREPARING FAA FORM 8120-10, REQUEST FOR

CONFORMITY U.S. Department REQUEST FOR CONFORMITY of Transportation RFC Tracking Number:

Federal Aviation Administration Revision: , Rev. Date: Page 1 of To: Attention:

Project No.:

Initial Date:

Request for Conformity Inspection Part Conformity Installation Other (Specify) A conformity inspection pertaining to the subject is requested for the following:

Applicant Name:

Company Name:

Street:

City: State: Zip:

Time/Date Available: Applicant will Contact FAA Type Installation:

Make/Model: Quantity:

Requesting Document (P.O.) and Date:

Design Data:

(with Rev/Date) Special .Instructions:

Applicant Contact: Phone:

FAA Project Manager: Phone:

FAA Project Engineer: Phone:

MIO Type Certification Mgmt. Spec: Phone:

MIDO Project Principal Inspector: Phone:

Remarks:

T.I.A. Issued (Type Inspection FAA Form 8100-1 Required (Conformity Authorization) Inspection Report) T.I.R. Required (Type Inspection FAA Form 8130-9 Required (Statement of Report) Conformity) 8130-3 Tags Required (Airworthiness Approval Tag) A-11

Appendix 4 Note: Please return this request for conformity with the Reviewed FAA Project Engineer, Axx-xxx FAA conformity documentation to the Project Principal By:Inspector (PI), then to the MIO Type Certification Management Specialist (TCMS), and then to the FAA Project Engineer (PE).

FAA Form 8120-10 (11-05) Supersedes Previous Edition (Representation)U.S.

Department of Transportation

REQUEST FOR CONFORMITY RFC Tracking Number:

Revision: Page of Federal Aviation Continuation Sheet DESIGN DATA (continued):

Special Instructions (continued):

Remarks (continued):

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