### Veterans Home Inspection Services LLC Henrey Dee Jetty 28 Larchwood Drive Pittsford NY 14534 Email: hjetty@rochest er . rr .co m 585-363-2848 (Call or text) NY Home Inspector Lie# 16000044801 US Department Of Transportation Federal Aviation Administration Civil Aviation Registry Aircraft Registration Branch (AFS-750) PO Box 25504 Oklahoma City, OK 73125-0504 June 17, 2015

Subject: Assignment of Registration Number for Exemption Application FAA Modernization and Reform Act of 2012 (Public Law 112-95). Section 333 of Public Law 112-95 Reference: US DEPT of Transportation Memorandum dated June 

### 5, 2015. Subject: Documents and Fees regarding DJI Phantom 

### 2, serial number PH645440916. Dear Sir or Madam: I am providing the information that was requested for the registration of my DJI drone. I have contacted the offices of DJI the manufacturer of the drone. They do not provide a transfer slip or any form of title with the purchase of their drones. I am unable to provide a completed AC Form 8050-2, Aircraft Bill of Sale Information. I am providing notarized documents stating that I am the first owner ofthis drone (serial number PH645440916). I purchased the drone from a company (Drones ECT.) thru Amazon website. I am attaching all receipts that were provided during my purchase of the drone. Included is a picture of the drone and serial number. Pursuant to Section 333 of the FAA Modernization and Reform Act of 2012(the reform act) and CFR Part 11 Veterans Home Inspection Services LLC, is the owner and operator of a Small Unmanned Aircraft Systems (UASs). Please contact me if there is any additional information that is required. Sincerely 

### COUNTY Of MONROE ss.: STATE OF NEW YORK} On this..tJ_day 

## ot:ll.nt ,20.J5., 

### before me, 

### the subscriber, personally appeared**Pine~ Qi~**  

### to me personally known and known to me to 

### I}the samef,erson de " bed in and who executed the within instrument and 

### _ h cknowl ed hat _he_ executed ti:Je- instrument

SARAH E. CLIMER Notary Public, State of New York No. 01CL6194707 Qualifi ed in Mon roe County My Commission Expires 1 0/06/20**I~** 

# . - ary 

### Public , · .:.:. -_ --- 2
-**:** 

# ----

- : 

### .....::U .S. Department of Transportation Federal Aviation Administration


### June 5, 2015

HENREY D JETTY 28 LARCHWOOD DRIVE PITTSFORDNY 14534 

### 1 ... 11.1,,1,1.1 ... 11 .. 1 .. 1

•• 11.1 

### Dear Mr. 

### Jetty : Flight Standards Service Aircraft Registration Branch, AFS-750 P .O . Box 25504 Oklahoma City, Oklahoma 73125-0504 (405) 954-3116 Toll Free: 1-866-762-9434 WEB Address: http://registry .faa.gov



### The Civil Aviation Registry has received the documents and fee concerning Dn PHANTOM 2, serial number PH645440916 . United States identification number T0051638 has been temporarily assigned. The following is required before we can assign a registration number and registration ofyour amateur built aircraft can be completed. a. Submit a complete Affidavit ofOwnership, signed before a notary public, and showing a description ofthe aircraft. The form attached to this letter meets our requirements and may be used ifyou wish. b . Submit documentary evidence ofownership (bill ofsale, invoice, receipt, etc.) from the manufacturer through all intervening owners ofthe aircraft to you, OR, submit a written affidavit stating when, where and how the aircraft was purchased, and why the evidence ofownership cannot be provided. You can find additional information at the FAA website on how to register unmanned aircraft at (http://www.faa.gov/licenses_certificates/aircraft_certification/aircraft_registry/UAI) Ifyou require further assistance, please contact the Aircraft Registration Branch at (405) 954-3116 or toll free 1-866-762-9434. Sincerely,

MAURICE COLEMAN Legal Instruments Examiner Aircraft Registration Branch Enclosure: 8050-88
AFS-700-LTR-1 (07/07)OMB Control No . 2120-0042 Exp . 11 /30/2014 Paperwork Reduction Act Statement: The information collected on this form is necessary to ensure applicant eligibility. The information is used to determine that the applicant meets the necessary qualifications as owner of an amateur built aircraft . We estimate that it will take approximately 30 minutes to complete the form. The information collection is required to obtain a benefit. The information collected becomes part of the aircraft registration system . 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. OMB 2120- 0042 . Comments covering the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at 800 Independence Avenue SW, Washington, DC 20591 . ATIN : Information Collection Clearance Officer, AES-200. AFFIDAVIT OF OWNERSHIP FOR AMATEUR-BUILT AND OTHER NON-TYPE CERTIFICATED AIRCRAFT (does not include light-sport) U.S . Identification 

### T0051638



# ----------------------------------------------------------------- Name ofAmateur I Non TC 'd builder 

### DJ I Phantom 2



# ---------------------------------------------------- Model 

### Phantom 2 Version 3 Serial Number 

### PH645440916 Class (airplane, rotorcraft, glider, weight shift control, powered-parachute, etc .) 

### Quadro-copter Drone (less than 

## 4 lbs) Type ofEngine Installed (reciprocating, turboprop, 2 or 4 cycle, electric, etc.) 

### Electric (battery operated) Manufacturer, Model and Serial Number ofeach Engine Installed 

### DJ I Phantom 

### 2 Version 

### 3

---------------------------------------- Number ofEngines Installed 

### _4 _______________ Built for Land or Sea Operation 

### land only Number of Seats 

### N/A



# ------------------- MUST CHECK ONE 

# D More than 50% of the above-described aircraft was built from miscellaneous parts and I am the owner. (This option is for aircraft eligible for amateur-built certification.) 

# D More than 50% of the above-described aircraft was built from a kit (prefabricated parts) and I am the owner. The bill of sale from the kit manufacturer is attached . (This option is for aircraft eligible for amateur-built certification .) 

# 0 I certify that the above-described aircraft is a newly built non-type certificated aircraft and is not currently registered in another country. (This option is for aircraft eligible for experimental certification other than amateur-built.) 

# 0 I certify that the above-described aircraft is a previously built (used) non-type certificated aircraft and is not currently registered in another country . (This option is for aircraft eligible for experimental certification other than amateur-built certification.) 

# D Evidence of ownership from the aircraft builder through any intervening owners is attached (chain of ownership). 

# 0 Unable to obtain complete chain of ownership . Statement as to ownership history and whereabouts of aircraft is attached. Name ofOwner: 

### Henrey Dee Jetty Signature ofOwner Address: City: 

### Pittsford Telephone: 

### 585-362-2848 Notary Public: State of : 

# N&.J'ioc K Subscribed and sworn to before me this

AC Form 8050-88 (03 / 12) Title of Signer (IfAppropriate): 

### Home Inspector

state: 

### New 

### York Zip: 

### 14534

County of : day of 

# 0VY'le

SARAH E. CLIMER Notary Public, State of New York No. 01 CL6194707 Qualified in Monroe 

### County My Commission Expires 10 / 00/21) & \t) 

# ao15



# --OMB Control No . 2120-0042 Exp. 11/30/2014 

### PRIVACY ACT STATEMENT: Privacy Act of 1974 (PL 93-579) requires that users ofthis form be informed ofthe authority which allows the solicitation ofthe information and whether disclosure ofsuch information is mandatory or voluntary ; the principal purpose for which the information is intended to be used; the routine uses which may be made ofthe information gathered; and the effects, ifany, ofnot providing all or any part ofthe requested information. Title 49, United States Code requires the registration ofeach United States civil aircraft as a prerequisite to its operation. An aircraft is eligible for registration only : ( 1) 

### ifit is not registered under the laws of any foreign country; and (2) ifit is owned by (a) a citizen ofthe United States ; or (b) an individual citizen of a foreign country who has lawfully been admitted for permanent residence in the United States ; or (c) a corporation lawfully organized and doing business under the laws ofthe United States or any State thereof so long as such aircraft is based and primarily used in the United States; or (d) a governmental unit. Operation of an aircraft that is not registered may subject the operator to a civil penalty. This form identifies the aircraft to be registered, and provides the name and permanent address for mailing the registration certificate. Incomplete submission will prevent or delay issuance ofyour registration certificate. The following routine uses are made ofthe information gathered: (1) To determine that aircraft are registered in accordance with provisions ofthe Title 49 , United States Code. (2) To support J he investigative efforts oLFederal, State and foreign government law**enforce nent**  agencies. (3) To serve as a repository oflegal documents used by individuals and title search companies to determine the legal ownership of an aircraft. (4) To provide aircraft owners and operators information about potential mechanical defects or unsafe conditions oftheir aircraft in the form of airworthiness directives. (5) To provide supporting information in court cases. (6) To serve as a data source for management information for production ofsummary descriptive statistics and analytical studies in support of agency functions for which the records are collected and maintained . (7) To respond to general requests from the aviation community or public for statistical information under the Freedom ofInformation Act or to locate specific individuals or specific aircraft for accident investigation, violation, or other safety related requirements. (8) To provide data for the automated aircraft registration master file . (9) To provide data for development ofthe aircraft registration statistical system. (10) To prepare an aircraft register in electronic media as required by ICAO agreement containing information on aircraft owners by name, address , N-Number, and type-aircraft, used for internal FAA safety program purposes and also available to the public (individuals, aviation organizations , direct mail advertisers , state and local governments, etc.) upon payment ofapplicable user charges reimbursing the Federal Government for its costs. (11) The aircraft records maintained by the Aircraft Registration Branch are public records and are open for inspection in Room 122 ofthe Registry Building, Mike Monroney Aeronautical Center, 6425 S Denning, Oklahoma City, Oklahoma. Individuals interested in such information may make a personal search ofthe records or may avail themselves ofthe services ofa title search company or law firm. 

### PLEASE REMOVE TIDS PORTION BEFORE SUBMITTING TO FAA.

AC Form 8050-88 (03112)

# HEN REV JEllY DRONE SERIAL NUMBER AND MODEL 

# Veterans Home Inspection Services Pittsford NY 14534 585-362-2848 

# • II

## HJETTY From: Sent: To: 

### Subject: Attachments: 

# amazon ........_.,-, Hell o henrey jetty , auto-confirm@amazon.com Wednesday, April 01, 2015 5:28 PM henrey jetty Your Amazon .com order of "BUNDLE Alpha DronePack with.. .". _Certification_.htm



### Order Confirmation

Thank you for shopping with us . You ordered " BUNDLE Al pha Dron e Pack with . .." . We'll send a confirmation when your item ships. 

### Deta ils Order #1 07-411 0147-6379436 Estimated delivery date: Tuesday, April 7, 

### 2015
- Thursday, April 9, 

### 2015 

## Vtf!NI 

## or manage order

We hope to see you again soon . Amazon.com Ship to : Henrey D Jetty 28 LARCHWOOD DR... Total Before Tax: $1,299
.00 Estimated Tax: $0
.00 Order Total: 

### $1,299.00



### Frequently Bought With B UNDLE Alph a DroneP. . . DJI Part28 Pha ntom 2 Series 9-lnch ... 

### $7 .09 2 Pa irs Genuine D JI Phantom 2 . .. $9
.99
The payment for your invoice is processed by Amazon Payments, Inc. P.O. Box 81226 Seattle, Washington 98108-1226 . If you need more information . please contact (866) 216-1075 Unless otherwise noted, items so ld by Amazon .com LLC are subject to sales tax in select states in accordance with the applicable laws of that state . If your order contains one or more items from a seller other than Amazon.com LLC , it may be subject to state and local sales tax . depend ing upon the seller's business policies and the location of their operations . Learn more about tax ana selle r 1 nformauon.Page 1 of 1 

# D R**~** 

# N E 

# s ETC 

## PACKING LIST: 

## 341417 Order No:107-4110147-6379436-DRN

Shipping Manager 4000 East Highway 6 Dock#47 Spanish Fork, UT 84660 US

CUSTOMER PO CARRIER SHIP TO: Henrey D Jetty Attn : Henrev D Jettv 28 LARCHWOOD DR PITTSFORD , NY 14534-2434 US TEL: 5856625896 ORDER DATE 107-4110147-6379436-DRN UPS Ground Residential w/ Signat 4/2/2015 ITEM LOT ID I EXPDate 

# I DESCRIPTION BUSINESSCARD DJI - PHT-VISP-3 DJI -VIS- BAT DP-ALPHA Packed 

### by--------- BLACK BUSINESS CARD DJI Phantom 2 Vision Plus Vers ion 3 .0 (upgraded version) P2 P2V BATTERY FOAM AND LID INS I DE CANVAS PACK TOTALS SHIPMENT NO 646906 

# I QTY SHIPPED 

# I UOM 

# I

4 EA EA EA EA