Form FAA-8130-12 Eligibility Statement, Amateur Built Aircraft

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U.S. Department
of Transportation
Federal Aviation
Administration

ELIGIBILITY STATEMENT
AMATEUR-BUILT AIRCRAFT
Supplemental Information and Instructions

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INFORMATION FOR APPLICANT

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 the 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:
This information is collected for the purpose of issuing a special airworthiness certificate for the purpose of
operating and amateur-built aircraft to any applicant meeting the criteria established in FAA Order 8130-2,
Airworthiness Certification of Aircraft and Related Products. The FAA uses the information to maintain and update
the current database of aircraft having obtained approved airworthiness certificates. The burden associated with
completing FAA Form 8130-12 is 15 minutes. Providing this information is mandatory if an applicant wishes to
obtain a special airworthiness certificate for the purpose of operating an amateur-built aircraft. The information is
protected under the provisions of the Privacy Act and the Privacy Act system of records DOT/FAA-801, Aircraft
Registration System. 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. 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 form.

FAA Form 8130-12 (08-2009) Supersedes Previous Edition

NSN:0052-00-889-9002

Form Approved
OMB NO. 2120-0018
Exp. 09/30/2017

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Instructions: Print or type all information except signature.
Submit original to an authorized FAA representative.
Applicant completes Section I thru III. Notary Public
Completes Section IV.

ELIGIBILITY STATEMENT
AMATEUR-BUILT AIRCRAFT

US Department
of Transportation
Federal Aviation
Administration

I. REGISTERED OWNER INFORMATION
Name(s)
Address(es)
No. & Street

City

State

Zip

Telephone No.(s)
Residence

Business
II. AIRCRAFT INFORMATION

Model

Engine(s) Make

Assigned Serial No.

Engine(s) Serial No.

Registration No.

Prop./Rotor(s) Make

Aircraft Fabricated:

Plan

D

Kit

D

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

III. MAJOR PORTION ELIGIBILITY STATEMENT OF APPLICANT
I certify that the major portion of this aircraft (identified in Section II above) was fabricated and assembled by

Names of all builders (Please Print)
solely for my (our) education or recreation, in accordance with 14 CFR part 21, Certification Procedures for Products and Parts, §

21.191(g), Operating amateur-built aircraft. I have records to support this statement and will make them available to the FAA upon

request.

During the fabrication and assembly of this project, I/ we used the following commercial assistance (mark N/A if no commercial

assistance was used):

Name of company or individual(s)

City & State

Phone

Name of companyor individual(s)

City & State

Phone

-NOTICEWhoever in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government 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 materially
false, fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing the same to contain
any materially false, fictitious or fraudulent statement or entry, shall be fined under this title, imprisoned not more than 5 years or, if the
offense involves international or domestic terrorism, imprisoned not more than 8 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

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IV. NOTARIZATION STATEMENT

FAA Form 8130-12

(08-2009) Supersedes Previous Edition

NSN:0052-00-889-9002