Form New Small UAS (sUAS) Operations Over People

Form Approved OMB No 2120-XXXX Exp mm/dd/yy

U.S. Department of Transportation Federal Aviation Administration	Small UAS (sUAS) Operations Over People Declaration of Compliance
1. Applicant Name		2. Applicant Address (street, city, state, zip)
3. Applicant Email Address
3. sUAS Serial Number(s) for which Applicant declares compliance:		4. sUAS Make:			5. sUAS Model:
6. sUAS Description:
7. Is this an Initial Declaration of Compliance or an Amended Declaration of Compliance?		8. If this is an Amended Declaration of Compliance, state the reason for resubmittal.
In the appropriate category or categories for eligibility to operate over people, list the means of compliance used for designing, producing, or modifying the sUAS listed above. Indicate whether the Administrator has already accepted the means of compliance.
9. Indicate for which category(ies) this declaration is made:
10. Category 2. Identify the means of compliance used to satisfy the Category 2 standard for operations over people. If available, list the means of compliance identification number. If no identification number exists, describe the status of the means of compliance application.
11. Category 3. Identify the means of compliance used to satisfy the Category 3 standard for operations over people. If available, list the MOC identification number. If no MOC identification number exists, describe the status of the MOC application.
12. Comments:
Your signature below indicates you declare you have fulfilled each of the following requirements. Submission of any false statement(s) on this submission are a violation of Title 14 Code of Federal Regulations (CFR) § 107.5 and could result in penalties under Title 18 United States Code § 1001.
DESIGN: I certify that the sUAS identified above, or series of sUAS identified in serial numbers above, fulfills the standards of Category 2, Category 3, or both. I understand the standards for these categories are codified at 14 CFR § 107.115 (Category 2) and 14 CFR § 107.120 (Category 3). I have demonstrated the sUAS, series of sUAS identified in the serial numbers above, or specific configurations of the sUAS, satisfies either or both standards through an accepted means of compliance.
MANUFACTURING: I certify that the sUAS identified above, or series of sUAS identified in serial numbers above, complies with quality assurance processes and procedures to ensure product repeatability and continued compliance with the performance-based standards of 14 CFR § 107.115, § 107.120, or both. I understand I must notify the FAA immediately if I am aware of any safety defects that could result in noncompliance with the aforementioned standards.
OPERATION: I certify that I have developed Remote Pilot Operating Instructions for the sUAS identified above or series of sUAS identified in serial numbers above, as applicable for operations over people in accordance with Category 2, Category 3, or both. I will ensure these instructions remain current and are readily available to operators. At a minimum, these instructions include: a description of the sUAS or series of sUAS, the declared category or categories of operation; modifications that will not change the eligibility of the sUAS for the category or categories of operation the sUAS are eligible to conduct; and instructions for how to verify and change the mode or configuration of the sUAS, if variable modes are available.
PRODUCT SUPPORT: I certify that I have established and will maintain a notification process to make notifications available to notify operators of updates that could affect the eligibility of the sUAS or series of sUAS to operate over people in accordance with Category 2, Category 3, or both. At a minimum, this notification process will notify the public and the FAA of: any defect or condition that causes the sUAS or series of sUAS to no longer meet the requirements of part 107, subpart C; and any identified safety defect that causes the sUAS or series of sUAS to exceed: for Category 2, a low probability of a casualty, or for Category 3, a low probability of a fatality.
FACILITY ACCESS: I certify that at the request of the FAA, I will allow the FAA to inspect my facilities, technical data, and any manufactured sUAS or series of sUAS that are the subject of this Declaration. I will also allow the FAA to witness any tests necessary to determine compliance with part 107, subpart C.
* Name			* Signature
Title:				*Date:
* Name			* Signature
Title:				*Date:

FAA Form

Part 107 Operations Over People Declaration of Compliance Form

The authority for collecting the information you provide on this form is codified at 49 U.S.C. §§ 44701 and 44807; see also 14 CFR part 107, subpart C. The principal purpose for which the FAA intends to use the information is to receive, evaluate, and respond to requests for acceptance of Declarations of Compliance that indicate eligibility to operate small UAS over human beings pursuant to 14 CFR part 107, subpart C. The information may include, but is not limited to, name, address, email address, small UAS make, model, and serial number(s), and information to verify the eligibility of the small UAS for operations over people. Disclosure of this information is mandatory if the person who designs, produces, or modifies a small UAS seeks to receive a determination of eligibility for operations over people under part 107, subpart C. Operation of a small UAS that is contrary to the restrictions of 14 CFR § 107.39 or that occurs without a waiver for the operation may result in an enforcement action and/or civil penalties under 14 CFR Part 13. Additionally, failure to provide all required information will result in the FAA being unable to determine the small UAS or series of small UAS that are the subject of a declaration is eligible for operations over people. The information collected on this website will be included in a Privacy Act System of Records known as [INSERT TITLE OF SYSTEM OF RECORDS NOTICE] Records from this system of records may be disclosed in accordance with the routine uses that appear in [INSERT TITLE OF SYSTEM OF RECORDS NOTICE AND FEDERAL REGISTER CITATION FOR SYSTEM OF RECORDS NOTICE].

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 21XX-XXXX. Public reporting for this collection of information is estimated to be approximately 50 hours 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 (14 CFR 107). 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