Form 8130-12 Eligibility Statement Amateur Built Aircraft

Form Approved OMB Control No. 2120-0018
Expiration Date: October 31, 2026

INFORMATION FOR APPLICANT
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.

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, 88 FR 53951 - August 9, 2023 the information will be routinely disclosed:


To the public (including government entities, title companies, financial institutions, international organizations, and others), when
permitted, information, including aircraft owner’s name, address, United States Registration Number, aircraft type, legal
documents related to title or financing of an aircraft and ADB–S summary reports, in order to facilitate aviation safety, security,
and commerce. Emails and telephone numbers of small unmanned aircraft system (sUAS) owners registered under 14 CFR part
48 will not be disclosed to the Public pursuant to this Routine Use.



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



To government agencies, whether Federal, State, Tribal, local or foreign, information necessary or relevant to an investigation of a
violation or potential violation of law, whether civil, criminal, or regulatory, that the agency is charged with investigating or enforcing;
as well as, to government agencies, whether Federal, State, or local responsible for threat detection in connection with critical
infrastructure protection

However, the three routine uses above are only some, but not all, of the published routine uses that are listed in SORN
DOT/FAA 801, Aircraft Registration System. Other general routine uses noted in the SORN may be applicable as well.
Disclosure: Submission of this information is voluntary; however, incomplete submission may result in delay or denial of your
request.

Tear off this cover sheet before submitting form.
FAA Form 8130-12 (06/20) SUPERSEDES PREVIOUS EDITION

Form Approved OMB Control No. 2120-0018
Expiration Date: October 31, 2026

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

Kit

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 company or 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

IV. NOTARIZATION STATEMENT

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