Major Repair and Alteration (Airframe, Powerplant, Propeller, or Appliance)
Major Repair and Alteration (Airframe, Powerplant, Propeller, or Appliance)
Form Approved OMB No. 2120-0020 For FAA Use Only Office Identification
INSTRUCTIONS: Print or type all entries. See FAR 43.9, FAR 43 Appendix B, and AC 43.9-1 (or subsequent revision thereof) for instructions and disposition of this form. This report is required by law (49 U.S.C. 1421). Failure to report can result in civil penalty not to exceed $1,000 for each such violation (Section 901 Federal Aviation Act of 1958). Make 1. Aircraft Serial No. Name (As shown on registration certificate) 2. Owner Model Nationality and Registration Mark Address (As shown on registration certificate)
AIRFRAME
POWERPLANT
C. Certificate No.
D. I certify that the repair and/or alteration made to the unit(s) identified in item 4 above and described on the reverse or attachments hereto have been made in
accordance with the requirements of Part 43 of the U.S. Federal Aviation Regulations and that the information furnished herin is true and correct to the best of my knowledge.
Date
7. Approval for Return To Service Pursuant to the authority given persons specified below, the unit identified in item 4 was inspected in the manner prescribed by the REJECTED APPROVED Administrator of the Federal Aviation Administration and is FAA Flt. Standards Inspector BY FAA Designee Date of Approval or Rejection Repair Station Certificate or Designation No. Manufacturer Inspection Authorization Person Approved by Transport Canada Airworthiness Group Signature of Authorized Individual Other (Specify)
NOTICE
Weight and balance or operating limitation changes shall be entered in the appropriate aircraft record. An alteration must b e compatible with all previous alterations to assure continued conformity with the applicable airworthiness requirements.
8. Description of Work Accomplished (If more space is required, attach additional sheets. Identify with aircraft nationality and registration mark and date work completed.)
Paperwork Reduction Act Statement: The reason for collecting this information is to track major maintenance performed on aircraft. The collected information is used as part of the aircraft's historical file. The public reporting burden for this collection of information is estimated to average 30 minutes per response. Responses are mandated by 14 CFR Part 43. Collected information becomes part of the public record and no confidentiality is required. 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. The OMB control number associated with this collection is 2120-0020.
Electronic Version (Adobe)