OMB Control No. 2120-0690
Exp. 04/30/2017
AFFIDAVIT OF OWNERSHIP
Paperwork Reduction Act Statement: The information collected on this form is necessary to ensure applicant eligibility. The information
is used to determine that the applicant meets the necessary qualifications as owner of an experimental or special light-sport aircraft. We
estimate that it will take approximately 30 minutes to complete the form. The information collection is required to obtain a benefit. The
information collected becomes part of the aircraft registration system. Please note that an agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. OMB 2120-0690.
Comments covering the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at 950 L’Enfant
Plaza SW, Washington, DC 20024, ATTN: Information Collection Clearance Officer, AES-200.
LIGHT-SPORT AIRCRAFT MANUFACTURER’S AFFIDAVIT
U. S. Identification
Manufacturer
Model
Serial Number
Class (airplane, gyroplane, weight-shift-control,
powered parachute, balloon, airship, glider)
Land or Sea Operation
Type of Engine installed (2 cycle, 4 cycle)
Engine Manufacturer
Engine Model
Serial Number
Number of Seats
DECLARATION
First option: I certify that the aircraft descr bed above is a newly manufactured aircraft; that it will meet all applicable consensus
standards under 14 CFR 21.190; and the aircraft is not currently registered in another country. Dealer’s Aircraft Registration
Certificate No.
(if applicable).
Second option: I certify that the aircraft descr bed above is a newly manufactured unassembled aircraft that meets all applicable
consensus standards under 14 CFR 21.191(i)(2); and the aircraft is not currently registered in another country. Dealer’s Aircraft
Registration Certificate No.
(if applicable).
Name of Manufacturer:
Signature of Manufacturer:
Title of Signer (If Appropriate)
Address:
City:
State:
Zip Code:
Country:
Telephone:
Notary Public (or a person authorized under local law to administer oaths):
State of
County of
Subscribed and sworn to before me this
day of
,
My Commission Expires:
(Signature of Notary Public)
(Seal required is applicable in your State)
AC Form 8050-88A (10/11)