Form 8130-12 Eligibility Statement Amateur Built Aircraft

Form Approved OMB No. 2120-0018
Expires: January 31, 2021

INFORMATION FOR APPLICANT
Privacy Act Statement
Privacy Act Statement (5 U.S.C. § 552a(e)(3))
Authority: The authority for collecting this information on FAA Form 8130-12, Eligibility Statement Amateur-Built Aircraft is
contained in 49 U.S.C. § 44103 as implemented by 14 CFR Part 21.
Purpose: 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.
Routine Uses: In accordance with the Privacy Act System of Records Notice (SORN), DOT/FAA 801, Aircraft Registration
System, will be routinely disclosed:


To the public (including government entities, title companies, financial institutions, international organizations, FAA
designee airworthiness inspectors, and others) information, including aircraft owner’s name, address, United States
Registration Number, aircraft type, legal documents related to title or financing of an aircraft, and ADS–B summary
reports. Email addresses, credit card information, and telephone numbers of small unmanned aircraft system (sUAS)
owners registered under 14 CFR part 48 will not be disclosed pursuant to this Routine Use. The public may only
retrieve the name and address of owners of sUAS registered under 14 CFR part 48 by the unique identifier displayed
on the aircraft.



To law enforcement, when necessary and relevant to a FAA enforcement activity.

The Department has also published 15 additional routine uses applicable to all DOT Privacy Act system of records. These
routine uses are published in the Federal Register at 84 FR 55222 - October 15, 2019 and 77 FR 42796 - July 20, 2012, and
under ‘‘Prefatory Statement of General Routine Uses’’ (available at https://www.transportation.gov/privacy/privacyactnotices).
Disclosure: Submission of this information is voluntary; however, incomplete submission may result in delay or denial of your
request.

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 currently 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, 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 benefits per 14 CFR Part 21. 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.

Tear off this cover sheet before submitting form.

FAA Form 8130-12 (06/20) SUPERSEDES PREVIOUS EDITION

Form Approved OMB No. 2120-0018
Expires: January 31, 2021

0

US Department
of Transportation
Federal Aviation
Administration

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

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

I
IV. NOTARIZATION STATEMENT

FAA Form 8130-12 (06/20) SUPERSEDES PREVIOUS EDITION