FAA-8130-12 Eligibility Statement, Amateur Built Aircraft

Form Approved

OMB NO. 2120-0018

02/28/2013

Instructions: Print or type all information except signature.
US Department
of Transportation
Federal Aviation
Administration

Submit original to an authorized FAA representative.

ELIGIBILITY STATEMENT
AMATEUR-BUILT AIRCRAFT

Applicant completes Section I thru Ill.
Notary Public Completes Section IV.

I. REGISTERED OWNER INFORMATION
Name(s)
Address(es)

No. & Street

Telephone No.(s)

City

State

Zip

Business

Residence

II. AIRCRAFT INFORMATION
Model

Engine(s) Make

Assigned Serial No.

Engine(s) Serial No.

Registration No.

Prop./Rotor(s) Make

Aircraft Fabricated:

Plan

Prop./Rotor(s) Serial No.(s)

Kit

Ill. MAJOR PORTION ELIGIBILITY STATEMENT OF APPLICANT

I certify
by

the

aircraft

identified in Section

II

above

was

fabricate

and

assembled

Name of Person(s)(Please Print)

for my (their) education or recreation. I (we) have records to support this statement
make them available to the FAA upon request.

and

will

-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
or 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 (4-03) Supersedes Previous Edition

NSN:0052-00-889-9002

ELIGIBILITY STATEMENT
AMATEUR-BUILT AIRCRAFT

U.S. Department
of Transportation
Federal Aviation
Administration

Supplemental Information and Instruction

Privacy Act Statement

Information on FAA Form 8130-12, Eligibility Statement, Amateur-Built Aircraft, is solicited under the authority of
49 U.S.C. 44103 as implemented by 14 CFR Part 21. The purpose of this information is for the applicant to
certify that major portion of the aircraft was fabricated and assembled for their own education or recreation.
Submission of this data is mandatory and will become part of the Privacy Act system of records DOT/FAA 801,
Aircraft Registration System. Incomplete submission may result in delay or denial of your request. Information
maintained in the Privacy Act system of records is routinely used to (1) provide aircraft owners and operators
information about potential mechanical defects or unsafe conditions of their aircraft in the form of airworthiness
directives, (2) locate specific individuals or aircraft for accident investigation, violation, or safety related
requirements, (3) prepare an Aircraft Registry in magnetic tape and microfiche form as required by ICAO
agreement, containing information on aircraft owners by name, address, United States Registration Number,
and type of aircraft, and (4) DOT Prefatory Statement of General Routine Uses.

Paperwork Reduction Act Statement:

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject
to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction
Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for
this information collection is 2120-0018. Public reporting for this collection of information is estimated to be
approximately 15 minutes per response, including the time for reviewing instructions, completing and reviewing the
collection of information. All responses to this collection of information are required to obtain or retain benefits under
the authority of 49 U.S.C. 44702 as implemented by 14 CFR Part 21. The information is protected under the provisions
of the Privacy Act and the Privacy Act system of records DOT/FAA-801, Aircraft Registration System.
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.

Tear off this cover sheet before submitting this form.

FAA Form 8130-12 (4-03) Supersedes Previous Edition

NSN:0052-00-889-9002