Form 2 FAA - 2120-0765 - DeRegistration Form & Instructions - F

OMB Control No. 2120-0765

Expiration XXX

Section 336 Aircraft Owner Request to Delete Registration/Receive Refund

This form is for owners of model aircraft who would like to delete their registration record in the small UAS registration database maintained under the Privacy Act System of Record DOT/FAA-801, Aircraft Registration Records, in accordance with the ruling in Taylor v. Huerta by the Court of Appeals for the District of Columbia Circuit on May 19, 2017.  In order to enable the deletion of your registration record in the small UAS registration database, the following stipulations must be applicable.  Please ensure they are properly marked as part of your certification. Once your request is accepted, all registrant information will be deleted. Should you wish to register your small UAS in the future, a new application and identifier will be required.

I hereby certify that I always operate exclusively in compliance with all of the following provisions of section 336:

• My sUAS is flown strictly for hobby or recreational use;

• My sUAS is operated in accordance with a community-based set of safety guidelines and within the programming of a nationwide community-based organization;

• My sUAS does not weigh more than 55 pounds unless it is otherwise certified through a design, construction, inspection, flight test, and operational safety program administered by a community-based organization;

• My sUAS is operated in a manner that does not interfere with and gives way to any manned aircraft; and

• When flown within 5 miles of an airport, I provide the airport operator and the airport air traffic control tower (when an air traffic facility is located at the airport) with prior notice of the operation.

• I understand that if I do not always operate exclusively in compliance with the above provisions of section 336, I am operating without a valid registration, which can result in civil and criminal penalties.

• I also understand that if I already received a refund during the grace period (December 21, 2015 – January 20, 2016) I am not eligible for another refund.

[ ] Expunge my record only, no refund required

(information on the second page not required, see second page for mailing address)

[ ] Expunge record and request refund

(include all required financial institution information on the second page)

Owner Name:

Owner Unique Identifier:

Signature:

Refund Processing Information

PAYEE INFORMATION
NAME
ADDRESS
CONTACT PERSON NAME:		TELEPHONE NUMBER: ( )

FINANCIAL INSTITUTION INFORMATION

NAME:
ADDRESS:
NINE-DIGIT ROUTING TRANSIT NUMBER:	-	- - - - - - -	-
DEPOSITOR ACCOUNT TITLE:
DEPOSITOR ACCOUNT NUMBER:				ILOCKBOX NUMBER:
TYPE OF ACCOUNT (CIRCLE ONE): HECKING		CHECKING SAVINGS LOCKBOX

Owner Name:

Owner Unique Identifier:

Signature:

Refunds will be distributed via electronic funds transfer to the requested bank account upon receipt and confirmation of the information on this form.

Please mail your completed form to:

FAA Civil Aviation Registry

PO Box 25504

Oklahoma City OK, 73125

PRIVACY ACT STATEMENT:

This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. Individuals may request deregistration of their small unmanned aircraft (sUAS) from the Small Unmanned Aircraft Registration Service pursuant to Section 336 of Pub. L. 112-95 and 5 U.S.C. 552a(d)(2). The principal purpose for which information collected is to verify that the owner’s sUAS is not required to be registered under 14 CFR 48 because it qualifies as a model aircraft under Section 336 of Pub. L. 112-95. The failure to provide the required information will prevent the FAA from deregistering your sUAS from the Small Unmanned Aircraft Registration Service. The information collected to deregister sUAS and complete the refund request to those owners who qualify and wish to delete their information is included in two Privacy Act System of Records known as DOT/ALL 7 and DOT/ALL 17. Records from these systems of records may be disclosed in accordance with the routine uses that appear in DOT/ALL 7, and DOT/ALL 17, available at https://www.transportation.gov/individuals/privacy/privacy-act-system-records-notices.

Paperwork Reduction Act Burden 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 currently valid OMB Control Number. The OMB Control Number for this information collection will be 2120-0765. Public reporting for this collection of information is estimated to be approximately 2 minutes per response.

All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110.

Instructions for completing this form:

1. On the first page, in order to self-certify, please check each applicable stipulation in the list of section 336 provisions. If each provision is not checked, your record deletion and refund will not be processed.

2. Select whether you would like to have your record expunged or have your record expunged and a refund processed.

3. Fill out your name, unique identifier number, and sign the page.

4. On the second page, fill out your bank information if you have selected the option to receive a refund.

5. Fill out your name, unique identifier number, and sign the page.

6. Mail your completed form to the Civil Aviation Registry address on the second page.