FAA-8130-9 Statement of Conformity

Form Approved
OMB: 2120-0018
02/28/2013

STATEMENT OF CONFORMITY
Section I - Aircraft
1. Make

2. Model
4. Registration No.

3. Serial No.

Section II - Engine
1. Make

2. Model

3. Serial No.

Section III - Propeller
1. Make

2. Hub Model

3. Blade Model

4. Hub Serial No.

5. Blade Serial No.

Section IV - Certification
I hereby certify that:

A. I have complied with Section 21.33(a).

B. The aircraft described above, produced under type certificate only (CFR 21 Subpart F), conforms to its type certificate,
is in a condition for safe operation, and was flight checked on
(Date)
C. The engine or propeller described above, presented herewith for type certification, conforms to the type design
therefor.
D. The engine or propeller described above, produced under type certificate only (CFR 21 Subpart F), conforms to its type
certificate and is in a condition for safe operation. The engine or, if applicable, the variable pitch propeller was subjected
by the manufacturer to a final operational check on
(Date)

Deviations:

Signature of Certifier
Organization
FAA Form 8130-9 (4-03) Supersedes Previous Edition

Title
Date
NSN: 0052-00-025-3002

INSTRUCTIONS
This form should be submitted to a representative of the Administrator under the following circumstances:
1. By the applicant for a type certificate or a supplemental type certificate at the time he presents an aircraft or parts thereof to the FAA for tests.
2. By the applicant for a type certificate or a supplemental type certificate for each engine or propeller submitted for type certification.
3. By the type certificate holder or licensee manufacturing products under a type certificate only, upon the initial transfer by him of the ownership of each
product or upon application for the original issue of an aircraft airworthiness certificate, or an Airworthiness Approval Tag (FAA Form 8130-3).
This form should be completed as follows:
Section I. Aircraft. Complete the pertinent part of any of only this section when certification covers an aircraft or part thereof.
Section II. Engine. Complete this section when certification covers an engine.
Section III. Propeller. Complete this section when certification covers a propeller.
Section IV. Certification.
Item A. Check this block when an aircraft or part thereof is presented for flight or ground tests during type certification or supplemental type certification.
Item B. Check this block when the holder or licensee of a type certificate only, initially transfers the ownership of an aircraft manufactured under the
type certificate, or applies for the original issuance of an airworthiness certificate.
Item C. Check this block when an engine or propeller is presented for type certification.
Item D. Check this block when an engine or propeller is presented for airworthiness approval and insert the date the product completed a final operational
check.
The certification must be signed by an authorized person who holds a responsible position in the manufacturing organization.

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 current 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 48 minutes per response, including the time for reviewing
instructions, completing and reviewing the collection of information. All responses to this collection of information
are required to obtain or retain benefits under the authority of 49 U.S.C. 44702 as implemented by 14 CFR Part
21. The information is protected under the provisions of the Privacy Act and the Privacy Act system of records
DOT/FAA-801, Aircraft Registration System.
Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to
the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer,
AES-200.

FAA Form 8130-9 (4-03) Supersedes Previous Edition

NSN: 0052-00-025-3002