OMB No. 2120-0003 08/31/2008 DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION ATA Code OPER. Control No. DISTRICT OFFICE 8. Comments (Describe the malfunction or defect and the circumstances under which it occurred. State probable cause and recommendations to prevent recurrence.) Enter pertinent data 2. MANUFACTURER MODEL/SERIES SERIAL NUMBER AIRCRAFT 3. POWERPLANT 4. PROPELLER 5. SPECIFIC PART (of component) CAUSING TROUBLE Part Name MFG. Model or Part No. Serial No. Part/Defect Location. AIR TAXI MFG. FAA COMMUTER OTHER MALFUNCTION OR DEFECT REPORT 1. A/C Reg. No. N- OPERATOR DESIGNATION Comp/Appl Name Manufacturer Model or Part No. Serial Number MECH. 6. APPLIANCE/COMPONENT (Assembly that Includes part) Part TT Part TSO Part Condition 7. Date Sub. Accident; Date FAA FORM 8010-4 (10-92) SUPERSEDES PREVIOUS EDITIONS Incident; Date Use this space for continuation of Block 8 (if required). PAPERWORK REDUCTION ACT STATEMENT: The information collected on this form is used to evaluate certification standards, maintenance programs, and regulatory requirements. The information is required to ensure safety in air transportation. It is estimated that it will take approximately 9 minutes to complete the form. Providing this information is mandatory. No assurance of confidentiality is given. 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. The control number for this collection of information is 2120-0003. 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, ABA-20 American LegalNet, Inc. www.FormsWorkflow.com REP.STA. Check a box below, if this report is related to an aircraft SUBMITTED BY: Optional Information: TELEPHONE NUMBER OPER. ( ) U.S. Department of Transportation Federal Aviation Administration Flight Standards Service Aviation Data Systems Branch P.O. Box 25082 Oklahoma City, OK 73125-5029 NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES AFS-620 Official Business Penalty for Private Use $300 BUSINESS REPLY MAIL FIRST CLASS PERMIT NO. 12438 WASHINGTON, D. C. Federal Aviation Administration AFS-620 (Alerts) P.O. Box 25082 Oklahoma City, OK 73125-5029 American LegalNet, Inc. www.FormsWorkflow.com