Affidavit of Ownership for Unmanned Aircraft (UA)
N-number: __________ Class: □ Airship □ Glider □ Airplane □ Rotorcraft □ Hybrid Lift □ Ornithopter □ Air Taxi
Manufacturer/Builder: _____________________________________ Model: ___________________
(Show full legal name of UA manufacturer or builder and UA model.)
Serial Number: □ Manufacturer: ______________________________________ OR
□ Standard Remote ID: ______________________________________ OR
□ Remote ID Broadcast Module: _______________________________
(For UA with Remote ID, must be the serial number of the standard remote identification UA or, if equipped, the serial number of the remote ID broadcast module.) (For UA without Remote ID, must be the manufacturer assigned serial number.) ONLY LIST ONE NUMBER
Engine Type: □ Electric □ 2 Cycle Reciprocating □ 4 Cycle Reciprocating □ Turbo - Fan/Prop/Shaft/Jet
Number of Engines: _______ Number of Seats (Air Taxi): _______ Max Takeoff Weight: ___________ lbs.
The Undersigned Owner Certifies:
Select and complete one of these statements or compose a statement for your situation addressing these issues.
___1) I purchased the UA described above as a new off-the-shelf item on (date) ___________________ from the manufacturer or retail vendor named _______________________________________ located in (city, state, country) _______________________________________________________. A manufacturer's bill of sale was not available at the time of purchase, and a receipt, invoice, or other evidence is (choose one) □ attached □ not available to confirm the purchase.
___2) The UA described above was built from a prefabricated kit. The kit bill of sale from the manufacturer to the undersigned or other evidence to prove the transaction is attached.
___3) The UA described above was built using miscellaneous parts.
___4) I purchased the used UA described above, the Bill of Sale signed by the seller is attached.
___5) I purchased the used UA described above from (seller's full name) ___________________________________
located in (city, state, country) ___________________________________ on (date) _____________
The required bill of sale signed by the seller is not available because ______________________
_____________________________________________________________________________
____________________________________________________________________________________.
Other evidence, such as a receipt or invoice, is attached as proof the transaction took place.
The undersigned affirms that the information and statements provided herein are correct, this UA is not registered under the laws of any foreign country, and I am the rightful owner.
Owner's Name(s):__David Grim LBJ Drone LC_____________________________________________________
Owner's Signature(s):___________________________________________________________________________
Printed Name of Signer(s):_______________________________________________________________________
Signer's Title(s): (if applicable) _________________________________________________________________________
NOTARY PUBLIC -- State of: __________________ County of: __________________ Country: _________________
Subscribed and sworn before me this: ____ day of: _____________, ________ Signature: __________________________ My Commission Expires: _____________
(Notary Public or individual authorized under local law to administer oaths) (Seal required if applicable in your State.)