Form Approved OMB: 2120-0018 12/31/2010 STATEMENT OF CONFORMITY Section I - Aircraft 1. Make 2. Model 3. Serial No. 4. Registration No. Section II - Engine 1. Make 2. Model 3. Serial No. Section III - Propeller 1. Make 2. Model 3. Blade Model 4. Hub 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 (14 CFR, part 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 type design. D. The engine or propeller described above, produced under type certificate only (14 CFR part 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 operation check on____________________________ (Date) Deviations: Signature of Certifier Organization FAA Form 8130-9 (11-08) Supersedes Previous Edition Title Date NSN: American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This form should be submitted to a representative of the Administrator under the following circumstnaces: 1. By the applicant for a type certificate or a supplemental type certificate at the time he presents an aircraft ro 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 licenscee 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 a 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 box whien 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 inser 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: This information on FAA form 8130-9, Statement of Conformity, is collected for the purpose of obtaining mandatory information by an applicant as stated below. The FAA uses the information to maintain and update the current database for products and parts during the type certification program and for original airworthiness approvals. The burden associated with completing Form 8130-9 is 48 minutes. Providing this information is mandatory by an applicant at the time the aircraft or aircraft parts are submitted for FAA tests during the type certification program, for each aircraft, aircraft engine, or propeller submitted for type certification, and by a TC holder or licensee manufacturing products under a TC only: (a) with the initial transfer of ownership of each product; (b) upon application for original use of an airworthiness certificate; or (c) Export Airworthiness Approval. The information is protected under the provisions of the Privacy Act and the Privacy Act system of records DOT/FAA-801, Aircraft Registration System. 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 of information is 2120-0018. 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. FAA Form 8130-9 (11-08) Supercedes Previous Edition NSN: 0052-00-025-3002 American LegalNet, Inc. www.FormsWorkflow.com