Form Pending UAS Remote Identification Declaration of Compliance

OMB No. 2120-xxxx Exp.xx/xx/xxxx

U.S. Department

Of Transportation Federal Aviation Administration

Information for Applicant

Unmanned Aircraft Systems (UAS) Remote Identification DECLARATION OF COMPLIANCE

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 is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are required to obtain or retain a benefit by 14 CFR Part 89. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.

Privacy Act Statement

This statement is provided pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a. The authority for collecting this information on FAA Form XXXX-XX, Remote Identification Equipage Requirements for Unmanned Aircraft Systems (UAS) Declaration of Compliance is contained in 49 U.S.C. §§ 106(f), 40101, 40103, 44701(a)(5), 44805, 44809, and section 22202 of Pub. L. 114-190 as implemented by 14 CFR Part 89. The purpose of this information is for the applicant to certify they are in compliance with applicable FAA accepted industry consensus standards. In accordance with the Privacy Act system this information is routinely used to (1) provide persons designing and producing standard remote identification UAS or limited remote identification UAS information about potential mechanical defects or unsafe conditions of their aircraft in the form of a non- compliance letter, (2) locate specific individuals or aircraft for accident investigation, violation, or safety related requirements, and (3) DOT Prefatory Statement of General Routine Uses. Submission of this data is mandatory and will become part of the Privacy Act system of records. Incomplete submission may result in delay or denial of your request.

UAS Remote Identification Declaration of Compliance

The remote identification of unmanned aircraft systems (UAS) is necessary to ensure public safety and the safety and efficiency of the airspace of the United States. Once your information is officially processed, you will receive an email notification from the FAA automated mailbox, stating that we have received your Declaration of Compliance.

Please note, UAS certified under Part 21 (in any equipped operation under this rule) must show compliance in accordance with Part 21 type certification procedures and the applicable airworthiness standards for all systems aboard the aircraft, including Remote ID. UAS certified under Part 21 will file a paper copy of this form with their geographical Aircraft Certification Office (ACO). You will be contacted by the FAA if you are required to file a paper copy of this form. If you do not receive guidance from the FAA regarding certification of your aircraft under Part 21, then please continue filling out this form below. Complete the application below for your Declaration of Compliance to 14 CFR part 89, Remote Identification of Unmanned Aircraft Systems. To submit a Declaration of Compliance, you must be 13 years of age or older.

1. DESIGNER OR PRODUCER INFORMATION

First Name

Last Name

OR

Company Name

2. RESPONSIBLE PERSON’S INFORMATION

First Name

Last Name

Email Address

Confirm Email Address

Daytime Phone Number:

Prefix +

Area Code ( )

Number

Is this declaration of compliance an initial or amended declaration?

Initial

Amended

If this is an amended declaration of compliance, provide the initial DOC Tracking number assigned:

DOC #

If this is an amended declaration of compliance, is the re-submittal a result of a safety issue with a prior declaration of compliance?

Yes

No

If answered yes above, please briefly explain the safety issue:

3. DESIGNER’S/PRODUCER’S/RESPONSIBLE PERSON’S LOCATION INFORMATION

Physical Address (P.O. Boxes Not Allowed)

Mailing address (if different from physical address)

Address 1

Address 1

Address 2

Address 2

City

State

Postal Code

City

State

Postal Code

Country

Country

4. DATA INFORMATION

UAS Make

MOC Tracking Number(s)

UAS Model

UA Serial Number(s)

5. PRODUCER ACKNOWLEDGEMENTS

I acknowledge that the unmanned aircraft whose serial numbers are listed under this Declaration of Compliance comply with all applicable requirements of 14 CFR part 89 for remote identification of UAS, as identified in the following means of compliance. (List applicable MOC tracking number used for compliance in Section 4 of this form.)

I acknowledge that the person responsible for the production of UAS listed on this Declaration of Compliance will allow the Federal Aviation Administration to inspect the facilities identified in the DOC, as well as any associated technical data and any UAS produced, and to witness any tests necessary, to determine compliance with part 89.

I acknowledge that the person responsible for production of UAS listed on this Declaration of Compliance is responsible for conducting independent audits of the facilities, technical data, and any UAS produced listed under this Declaration of Compliance on a recurring basis to ensure compliance with the requirements of part 89, or if the FAA notifies the producer of non-compliance concerns of any UAS listed under this Declaration of Compliance.

I acknowledge that the person responsible for the production of UAS listed on this Declaration of Compliance has product support and notification procedures for the purpose of notifying operators and the FAA of any defect or condition that causes the UAS listed under the DOC to no longer meet the requirements of part 89.

I acknowledge that the person responsible for the production of standard remote identification UAS or limited remote identification UAS listed on this Declaration of Compliance has used 47 CFR-compliant radio frequency equipment and that equipment is integrated into the unmanned aircraft system without modification to its authorized radio frequency parameters.

If the FAA has designated that you need additional information to support your Declaration of Compliance, please attach to this form.