Form 3 Emissions Report (ER) CORSIA Eligible Fuels Annex (CEFA)

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Overview

Template Information
AO Identification
CEF Chain of Custody Form
CORSIA Eligible Fuel Claim Form
Summary

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Sheet 1: Template Information

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 2120-0790. Public reporting for this collection of information is estimated to be approximately 49 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524
US FAA CORSIA MRV Program
CORSIA ELIGIBLE FUELS SUPPLEMENTARY INFORMATION*
			(*supplementary information to the Emissions Report from aeroplane operator to State)
	CONTENTS
	Template information
	Aeroplane operator identification and reporting information
	CORSIA eligible fuel claim form
	Summary of CORSIA eligible fuels information
			- DRAFT -
	Template Information
	Template provided by:
	Version (publication date):

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Sheet 2: AO Identification

	AEROPLANE OPERATOR IDENTIFICATION AND REPORTING INFORMATION
a)	Name of aeroplane operator
	Please enter the name of the aeroplane operator. This name should be the legal entity carrying out the aviation activities.
a1)	Address of the aeroplane operator
	Please enter the address of the aeroplane operator.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
b)	Reporting year

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Sheet 3: CEF Chain of Custody Form

	CORSIA ELIGIBLE FUEL PRODUCER, PURCHASER, SHIPPER, AND BLENDER IDENTIFICATION INFORMATION
	Note: Please list the requested contact information for all parties involved in the chains of custody for which emissions reductions from the use of CORSIA eligible fuels are claimed using the CORSIA Eligible Fuels Claim Form process, please replicate this form as needed for additional parties. Parties need not be listed for which all information required by Annex 16, Volume IV, Appendix 5 Table A5-2 when claiming CORSIA Eligible Fuel is included in sustainability documentation attached.
a)	Identification of the producer(s) of the CORSIA eligible fuel
a1)	Name of producer 1 of the neat CORSIA eligible fuel
	Please enter the name of the fuel producer.
a2)	Address of producer 1 of the neat CORSIA eligible fuel
	Please enter the address of the producer of the neat CORSIA eligible fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
a3)	Location of the production of the neat CORSIA eligible fuel from producer 1
	Please enter the address of the production of the neat CORSIA eligible fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
a4)	Name of producer 2 of the neat CORSIA eligible fuel (if needed)
	Please enter the name of the fuel producer.
a5)	Address of producer 2 of the neat CORSIA eligible fuel
	Please enter the address of the producer of the neat CORSIA eligible fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
a6)	Location of the production of the neat CORSIA eligible fuel from producer 2
	Please enter the address of the production of the neat CORSIA eligible fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
a7)	Name of producer 3 of the neat CORSIA eligible fuel (if needed)
	Please enter the name of the fuel producer.
a8)	Address of producer 3 of the neat CORSIA eligible fuel
	Please enter the address of the producer of the neat CORSIA eligible fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
a9)	Location of the production of the neat CORSIA eligible fuel from producer 3
	Please enter the address of the production of the neat CORSIA eligible fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
b)	Intermediate purchaser 1 (if needed)
	If the aeroplane operator claiming emissions reductions from the use of CORSIA eligible fuels is not the original purchaser of the fuel from the producer (e.g., the aeroplane operator purchased fuel from a broker or a distributor), include the identity and contact information of these purchaser(s).
b1)	Name of the intermediate purchaser 1.
	Please enter the name of the intermediate purchaser 1.
b2)	Address of the intermediate purchaser 1.
	Please enter the address of the intermediate purchaser 1.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
b3)	Intermediate purchaser 2 (if needed)
	Please include the identity and contact information of the intermediate purchaser 2.
b4)	Name of the intermediate purchaser 2.
	Please enter the name of the intermediate purchaser 2.
b5)	Address of the intermediate purchaser 2.
	Please enter the address of the intermediate purchaser 2.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
c)	CORSIA eligible fuel shipper(s)
c1)	Name of the CORSIA eligible fuel shipper 1.
	Please enter the name of the party responsible for shipping of the neat CORSIA eligible fuel to the fuel blender.
c2)	Address of the CORSIA eligible fuel shipper 1.
	Please enter the address of the party responsible for shipping of the neat CORSIA eligible fuel to the fuel blender.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
c3)	Name of the CORSIA eligible fuel shipper 2. (If needed)
	Please enter the name of the party responsible for shipping of the neat CORSIA eligible fuel to the fuel blender.
c4)	Address of the CORSIA eligible fuel shipper 2.
	Please enter the address of the party responsible for shipping of the neat CORSIA eligible fuel to the fuel blender.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
d)	Fuel blender(s)
d1)	Name of the fuel blender 1
	Please enter the name of the party responsible for blending neat CORSIA eligible fuel with aviation fuel.
d2)	Address of the fuel blender 1
	Please enter the address of the party responsible for blending neat CORSIA eligible fuel with aviation fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
d3)	Location of blending 1
	Please enter the location where the neat CORSIA eligible fuel is blended with aviation fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
d4)	Name of the fuel blender 2
	Please enter the name of the party responsible for blending neat CORSIA eligible fuel with aviation fuel.
d5)	Address of the fuel blender 2
	Please enter the address of the party responsible for blending neat CORSIA eligible fuel with aviation fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:
d6)	Location of blending 2
	Please enter the location where the neat CORSIA eligible fuel is blended with aviation fuel.
	Address:
	City:
	State/Province/Region:
	Postcode/ZIP:
	Country:

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Sheet 4: CORSIA Eligible Fuel Claim Form

	CORSIA ELIGIBLE FUEL CLAIM FORM
	Note: complete one column of this form for each batch for which any CORSIA eligible fuels are claimed using the CORSIA Eligible Fuel Claim form.
	For additional claims of emissions reductions from the use of CORSIA eligible fuels, please replicate this form and fill separately. This form need not be used in cases where all information required by Annex 16, Volume IV, Appendix 5 Table A5-2 when claiming CORSIA Eligible Fuel is included in sustainability documentation attached.
a)	Chain of custody information
a1)	Fuel Claim #:
a2)	Name of producer of the neat CORSIA eligible fuel
a3)	Name of the intermediate purchaser 1 (if needed).
a4)	Name of the intermediate purchaser 2 (if needed).
a5)	Name of the CORSIA eligible fuel shipper.
a6)	Name of the fuel blender
b)	Purchase or shipment date(s) Please enter the date or date range when the neat CORSIA eligible fuel was purchased or shipped from the blender. Use the format yyyy-mm-dd.
c)	Production information
c1)	Date of production of the neat CORSIA eligible fuel Please enter the date of production of the neat CORSIA eligible fuel. Use the format yyyy-mm-dd.
c2)	Batch identification number:
c3)	Mass of each batch of neat CORSIA eligible fuel produced Please enter the total mass of each batch of neat CORSIA eligible fuel produced (in tonnes).
c4)	Type of fuel Please enter the type of fuel (i.e., Jet-A, Jet-A1, Jet-B, AvGas) for the purpose of computation of Life Cycle Emissions factors.
c5)	Feedstock type Please enter the information on the feedstock used to create the neat CORSIA eligible fuel.
c6)	Conversion process Please enter the conversion process (i.e., a type of technology used to convert a feedstock into neat CORSIA eligible fuel).
c7)	Percentage of batch purchased If less than an entire batch of neat CORSIA eligible fuel is purchased, please enter the proportion of neat CORSIA eligible fuel batch purchased (in percentage terms).
c8)	Mass of batch purchased Please enter the mass of CORSIA eligible fuel batch purchased (in tonnes).
c9)	Sustainability documentation Please provide evidence that the fuel satisfies the CORSIA Sustainability Criteria i.e., reference of attached valid certification document.
c10)	Default or Actual Life Cycle Emissions value (LSf) Please enter the Life Cycle Emissions value (in gCO2e/MJ).
c11)	Default or Actual Core Life Cycle Assessment (LCA) value Please enter the Core Life Cycle Assessment (LCA) value (in gCO2e/MJ).
c12)	Default Induced Land Use Change (ILUC) value Please enter the Induced Land Use Change (ILUC) value (in gCO2e/MJ).
d)	Blender information
d1)	Date the neat CORSIA eligible fuel was received Please enter the date the neat CORSIA eligible fuel was received by blender. Use the format yyyy-mm-dd.
d2)	Mass of neat CORSIA eligible fuel received Please enter the mass of neat CORSIA eligible fuel received (in tonnes).
d3)	Blend ratio of neat CORSIA eligible fuel and aviation fuel Please enter the blend ratio of neat CORSIA eligible fuel and aviation fuel.
d4)	Documentation demonstrating blending Please provide documentation demonstrating that the batch or batches of CORSIA eligible fuel were blended into aviation fuel (e.g., the subsequent Certificate of Analysis of the blended fuel).
d5)	Mass of neat CORSIA eligible fuel claimed Please enter the mass of neat CORSIA eligible fuel claimed (in tonnes).

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Sheet 5: Summary

	SUMMARY OF CORSIA ELIGIBLE FUELS INFORMATION
a1)	Summary of CORSIA eligible fuels (by fuel claim # from CEF Claim Form)
	Please provide a summary of the CORSIA eligible fuels claimed for the reporting year using the CORSIA Eligible Fuel Claim Form.
	Fuel claim #	Fuel type			Total mass of neat CORSIA eligible fuel claimed (in tonnes)		Life cycle emissions values of the CORSIA eligible fuel		Emissions reduction from CORSIA eligible fuels claimed (in tonnes)
		Type of fuel	Feedstock type	Conversion process
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	CORSIA ELIGIBLE FUEL PRODUCER, PURCHASER, SHIPPER, AND BLENDER IDENTIFICATION INFORMATION
a2)	Summary of CORSIA eligible fuels claimed using sufficient sustainability documentation
	Please provide a summary of the CORSIA eligible fuels claimed for the reporting year where all information required by Annex 16, Volume IV, Appendix 5 Table A5-2 when claiming CORSIA Eligible Fuel is included in sustainability documentation attached to this summary.
	Producer #	Producer name		Fuel type			Total mass of neat CORSIA eligible fuel claimed (in tonnes)		Life cycle emissions values of the CORSIA eligible fuel		Emissions reduction from CORSIA eligible fuels claimed (in tonnes)
				Type of fuel	Feedstock type	Conversion process
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
b)	Summary of information of CORSIA eligible fuels claimed
b1)	Total of emissions reduction from CORSIA eligible fuels claimed (in tonnes)
	Please enter the sum of the values included in column "Emissions reduction from CORSIA eligible fuels claimed (in tonnes)" of the table above.