OMB Approved 2120-0552 06/30/2009 SUSPECTED UNAPPROVED PARTS REPORT Refer to page 2 for instructions on how to complete this form. 1. Date the Part was Discovered: 2. Part Name: 3. Part Number: 4. Part Serial Number: 5. Quantity: 6. Assembly Name: 7. Aircraft Make & Model: Assembly Number: 8. Name, Address, and Description of the Company or Person Who Supplied or Repaired the Part: Street Address: Name: City: State: Country: ZIP Code: Phone Number: Check One of the Following Applicable to the Company or Person Who Supplied or Repaired the Part: Air Carrier – Certificate # Supplier Mechanic – Certificate # Production Approval Holder Repair Station – Certificate # Manufacturer Distributor Other Owner/Operator Unknown 9. Description of the Issue: 10. Name and Address of (the Company or Person) Where the Part Was Discovered: Street Address: Name: City: State: Country: ZIP Code: Phone Number: Check One of the Following Applicable to the Company or Person Who Discovered the Part: FAA Inspector Air Carrier – Certificate # Mechanic – Certificate # DOT/Office of Inspector General Repair Station – Certificate # Defense Criminal Investigation Service Distributor Other Government Agency Supplier Foreign Civil Aviation Authority Production Approval Holder Owner/Operator Unknown Other 11. Date of This Report: 12. Check this box if you request anonymity – Do Not Complete blocks 13-15. 13. Name and Address of the Reporter: Street Address: Name: City: Country: State: ZIP Code: Phone Number: 14. Check this box if you request confidentiality. 15. Check this box if you do not wish to receive an acknowledgement letter. 16. Check this box if you have attached additional information. FAA Form 8120-11 (10/16/2003) Supersedes Previous Edition Local Reproduction Authorized American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing FAA Form 8120-11, Suspected Unapproved Parts Report 1. 2. 3. 4. 5. 6. Record the date the part was discovered. Record the part name (or a description of the part). Record the part number or identification number of the part. Record the serial number on the part, if applicable. Record the quantity of parts. Record the assembly name and assembly number (where the part was or could be installed). Example: Part Name: Strut Part Number: PN 12345 Serial Number: 678 Assembly Name: Main Landing Gear Assembly Number: PN 90101112 Quantity: 1 NOTE: Record additional part numbers on page 3 or a blank sheet of paper with the following column headers: Part Name — Part Number — Serial Number — Quantity — Assembly Name — Assembly Number 7. Record the type of aircraft the part was (or could be) installed on. 8. Record the complete name and address of the company or person who produced, repaired, and/or sold the part. Do not list a P.O. Box address unless a street address is not available. Check the box that describes the company or person. Provide the certificate number, if known. Air Carrier An FAA-certificated company or person Supplier - A company or person who furnishes aircraft parts or who undertakes directly by lease, or other related services, at any tier, to the producer of a product or part arrangement, to engage in air transportation. thereof. Mechanic - A person holding an FAA mechanic Production Approval Holder - A company or person holding certificate with airframe and/or powerplant ratings. one of the following four types of FAA production approvals: production certificate, approved production inspection system, parts manufacturer approval, or technical standard order authorization. Repair Station - An FAA-certificated repair station. Manufacturer – The original equipment manufacturer (OEM.) Distributor - A broker, dealer, reseller or other person or agency engaged in the sale of parts. Owner/Operator - The owner or operator of an aircraft. Other-Record other type of business. Unknown 9. Record a brief narrative stating why you believe the part is not approved. Include a description of the part (improper configuration, suspect marking, different material, etc.), where it was obtained, and what type of documentation was supplied with it. 10. Record the complete name and address of the location where the part was found. Check the appropriate block to reflect the affiliation of the company or person who discovered the part. 11. Record the date the FAA Form 8120-11 is being submitted. 12. Check this box if you request anonymity (do not wish to provide your identity), and do not complete 13, 14 or 15. 13. Record your name, address and phone number, if desired. This information will enable the FAA to contact you for additional information, if necessary. 14. Check this box if you request confidentiality of your personal information recorded in block 13. 15. Check this box if you do not wish to receive a letter acknowledging the FAA’s receipt of FAA Form 8120-11. 16. Check this box if you have provided additional information (photos, invoices, certification statements, etc.) Forward the completed FAA Form 8120-11, Suspected Unapproved Parts Report, to: FAA Suspected Unapproved Parts (SUP) Program Office, AVS-20 13873 Park Center Road, Suite 165 Herndon, VA 20171 Phone: (703) 668-3720 Fax: (703) 481-3002 An electronic copy of FAA Form 8120-11, Suspected Unapproved Parts Report, is available on the SUP Program Office’s website at http://www.faa.gov/aircraft/safety/programs/sups/. You may complete the electronic FAA Form 8120-11 and send it the SUP Program Office e-mail address via this website. Privacy Act and Paperwork Reduction Act Statement: 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 for this form is 2120-0552. This information is collected by the FAA's Suspected Unapproved Parts (SUP) Program, under the authority of 49 USC 44701. The information will be used to support SUP investigations and management reports. Submission of this information is voluntary, with questions limited to reduce any burden on the reporter. Completion of this form is estimated to take less than 9 minutes. Information collected is not available elsewhere and necessary to support the FAA’s commitment to promote safety. Information is routinely shared with law enforcement agencies for use in civil and criminal investigations. Information developed from this form is covered under the Privacy Act system of records DOT/FAA 52 and the routine uses of that system will apply. A reporter may request confidentiality of personal information to the extent permitted by the Freedom of Information Act (5 USC 552) and the Privacy Act (5 USC 552a). Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave.SW, Wahington DC 20591, Attn: Information Collection Clearance Officer, AIO-20 FAA Form 8120-11 (10/16/2003) Supersedes Previous Edition Local Reproduction Authorized American LegalNet, Inc. www.FormsWorkflow.com FAA Form 8120-11, Suspected Unapproved Parts Report Continuation Sheet Page ( ) of ( ) Part Name Part Number Serial Number FAA Form 8120-11 (10/16/2003) Supersedes Previous Edition Quantity Assembly Name Assembly Number Local Reproduction Authorized American LegalNet, Inc. www.FormsWorkflow.com