DEPARTMENT OF TRANSPORTATION-FEDERAL AVIATION ADMINISTRATION TRIENNIAL AIRCRAFT REGISTRATION REPORT MODEL STREET ÛÎTY STATE ZIP COUNTRY

Transcription

1 AIRCRAFT REGISTRATION NUMBER DEPARTMENT OF TRANSPORTATION-FEDERAL AVIATION ADMINISTRATION TRIENNIAL AIRCRAFT REGISTRATION REPORT SERIAL NUMBER FAA CODE ISSUANCE DATE N 207SH G FEBRUARY 16, 2010 MAKE MODEL AAI CORP SHADOW 200B NAME AND ADDRESS OF CERTIFICATE HOLDER AAI CORP 124 INDUSTRY LN HUNT VALLEY MD GUIDELINES FOR REPORT COMPLETION: Cmplete ONLY if infrmatin is incrrect. Signature requirements: -Individual wner must sign. -Partnership, a general partner must sign. -Crpratin, a crprate fficer r managing fficial must sign- -C-wner, each c-wner must sign, cntinuing as necessary n an attached sheet- -Gvernment, any authrized persn may sign. > (D T3 P+ (D.a. 0) 7, > v w CANCELLATION OF REGISTRATION REQUESTED: (check applicable blck, sign, and date! 1. Aircraft sld t: (Purchaser's name and address) ADDRESS CHANGE REQUESTED (If address is a P. O. Bx, a physical address must als be prvided.) 2. Aircraft destryed/scrapped 3. Aircraft exprted t STREET 4. Other, specify (we) request cancellatin f registratin fr the abve reasn. STATE ZIP COUNTRY TITLE DATE SIGNATURE TITLE DATE Frm MANAGERIAL SITION (6-2003) Supersedes previus editin ÛÎTY MANAGERIAL POSITION

2 a p e s J J2/3& - 0/26 < J 2 cx CD -J- CD U. < CO Cl e z (.1 err : t " a CO Q i - CVI CET - j err c EZ U - O cx S C^J r < TO: Civil Aviatin Registry AFS-750 x j Mike Mnrney Aernautical Center <g P.O. Bx * Oklahma City, Oklahma i ^ - 0 4

3 di , Rev. 4/14/2010 DOCUMENT LEVEL ANNOTATIONS

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5 y STORM APPROVED IMmb N UNITED STATES OF AMERICA DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION-HIKE MONRONEY AERONAUTICAL CENTER AIRCRAFT REGISTRATION APPLICATION ' UNITED STATES REGISTRATION NUMBER N AIRCRAFT MANUFACTURER & MODEL M X ; drpàfct-ktfn Sh c n ujâûôa AIRCRAFT SERIAL N. OQQis^a TYPE OF REGISTRATION (Check ne bx) ( 3 m CERT. lasue DATE E f B ? iç (pss 9 ^ FOR FAjjjqUSE ONLY 1. Individual 2. Partnership $ 3. Crpratin 4. C-wner 5. Gv't. 8. NAME OF APPLICANT (Persn(s) shwn n evidence f wnership. If individual, give last name, first name, and middle initial.) Crpratin z C r d u s - t e y L a n e \ J c U l e y, n\ ^ X TELEPHONE NUMBER: ( j / fl ) [q\j, ~ \ if Q Q ADDRESS (Permanent mailing address fr first applicant listed.) Number and street: Rural Ruter STATE P.O. Bx: ZIP CODE M Ù CHECK HERE IF YOU ARE ONLY REPORTING A CHANGE OF ADDRESS ATTENTION! Read the fllwing statement befre signing this applicatin. This prtin MUST be cmpleted. A false r dishnest answer t any questin in this applicatin may be grunds fr punishment by fine and / r imprisnment (U.S. Cde, Title 18, Sec. 1001). l/we CERTIFY: CERTIFICATION (1) That the abve aircraft is wned by the undersigned applicant, wh is a citizen (including crpratins) f the United States. (Fr vting trust, give name f trustee: CHECK ONE AS APPROPRIATE: a. A resident alien, with alien registratin (Frm r Frm 1-551) N. b. A nn-citizen crpratin rganized and ding business under the laws f (state). and said aircraft is based and primarily used in the United States. Recrds r flight hurs are available fr inspectin at (2) That the aircraft is nt registered under the laws f any freign cuntry; and (3) That legal evidence f wnership is attached r has been filed with the Federal Aviatin Administratin..), r: NOTE: If executed fr c-wnership all applicants must sign. Use reverse side if necessary. TYPE OR PRINT NAME BELOW SIGNATURE TITLE DATE è I 11 SIGNATURE TITLE DATE NOTE Pending receipt f the Certificate f Aircraft Registratin, the aircraft may be perated fr a perid nt in excess f 90 days, during which time the PINK cpy f this applicatin must be carried in the aircraft. AC Frm (12/90) ( ) Supersedes Previus Editin C ^ ^ P ^ - Ô - FILING COPY

6 FILED WITH FAA AIRCRAFT REGISTRATION BR 200? FEB 20 m OKLAH'OMAiCITY O ^ C TV r<> c P r cp c - O CJ ^ tp. -A p- CP cn <j> -A y O -x- CP"

7 Paperwrk Reductin Act Statement: The infrmatin cllected n this frm is necessary t ensure applicant eligibility. The ill infrmatin is used t determine that the applicant meets the necessary qualificatins as wner f an amateur built aircraft. We till estimate that it will take apprximately 30 minutes t cmplete the frm. The infrmatin cllectin is required t btain a benefit. The infrmatin cllected becmes part f the aircraft registratin system. Please nte that an agency may nt cnduct r spnsr, and a persn is nt required t respnd t, a cllectin f infrmatin unless it displays a currently valid OMB cntrl number. OMB AFFIDAVIT OF OWNERSHIP FOR EXPERIMENTAL AIRCRAFT INCLUDING AMATEUR-BUILT AIRCRAFT AND OTHER NON-TYPE CERTIFICATED AIRCRAFT (des nt include light-sprt) U. S. Identificatin Experimental Aircraft N207gt4 Name f Amateur built builder OR A 00 5"7 1 *f Name f Nn TC'd manufacturer AAI Crpratin Mdel Shadw200B SerialNumber COUVCYANCC RECORDED Class (airplane, rtrcraft, glider, weight shift cntrl, pwered-parachute, etc.) Aircraft Unmanned Type f Engine Installed (reciprcating, turbprpeller, 2 r 4 cycle, etc.) Rtary - 4 Cycl^OO? ieb 26 Pfl 1 17 Number f Engines Installed One(1) FEDERAL AVIAT10 N Manufacturer, Mdel and Serial Number f each Engine Installed UAV Engines Ltd. ; AD M i N i STR AT 10 N Mdel #1100; Serial #605 (if ISP m Built fr Land r Sea Operatin Land Number f Seats Zer (0) MUST CHECK ONE Mre than 50% f the abve-described aircraft was built frm miscellaneus parts and I am the wner. (This ptin is fr amateur-built aircraft.) Mre than 50% f the abve-described aircraft was built frm a kit (prefabricated parts) and I am the wner. The bill f sale frm the kit manufacturer is attached. (This ptin is fr amateur-built aircraft.) / I certify that the abve-described aircraft is a newly manufactured nn-type certificated aircraft and is nt currently registered in anther cuntry. (This ptin is fr manufacturers nly.) I certify that the abve-described aircraft is a previusly manufactured (used) nn-type certificated aircraft and is nt currently registered in anther cuntry. Evidence f wnership frm the aircraft manufacturer thrugh any intervening wners is attached. (This ptin is fr wners f previusly manufactured aircraft nly.) Name f Owner: AAI Crpratin ; i-s- / Signature f OwnenC ^ f Signer (If Apprpriate): VP & General Cunsel Address 54 Industry Lane City: Hunt Valley State: MD Zip: Telephne: Ntary Public: State f: f/1 fl H/) (d/x) c/ Cunty f: Subscribed and swrn t befre me this I I day f febyu-ua, My Cmmissin E x ^ J W if I, A\\ : ; / j!l I j J l J k ^ r r - j, Alisn A. Rbinsn (Signa^Tf Ntary Public) ^ d C u n ^ AC Frm (01/07) " " My S s S. * August 1,2010 ^ > Q-I^/? CERTIFIED COPY-TO BE RECORDED ^gf v// rrn ^ xaks ^ OfpA'% 10 FEB

8 COMP, I have cmpared the same is a true ai N CERTIFICATE ing instrument with this riginal and it cpy theref in all respects. VWÔHVDI0 À1ID VH0HV1M0 II I m 02 81J M «8 N0I1VH1SI53«1 jvmomiv VVJ HUM 031U