OMB Control No. 2120·0042 Exp.11130/2014 Paperwork Reduction Act Statement: The infonnation collected onthis 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 ofthe aircraft registration system. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection ofinformation unless it displays a currently valid OMB control number. OMS 2120- 0042. Comments covering the accuracy ofthis burden and suggestions for reducing the burden should be directed to the FAA at 800 Independence Avenue SW, Washington, DC 20591. ATTN: Information Collection Clearance Officer, AES-200. 

### AFFIDAVITOF OWNERSHIP FORAMATEUR-BUILTAND OTHER NON-TYPE CERTIFICATED AIRCRAFT (does not include light-sport) U.S.Identification Name ofAmateur/Non TC'dbuilder 

## OJI Innovations 

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

## S1000 Serial Number 

## PH696150044 Class (airplane, rotorcraft, glider, weight shift control, powered-parachute, etc.) 

## Rotorcraft Type ofEngine Installed (reciprocating,turboprop, 2 or4 cycle, electric, etc.) 

## Electric Manufacturer,Model and Serial Number ofeach EngineInstalled 

## ~D_J_I_In_n_o_v_a_t_io_n_s

## _________ _ Model: 4114 Pro KD400 S/N: N/A Number ofEnginesltlStalled _8 _______ _ Built for Land or Sea Operation 

## _L_a_n_d __________ Number ofSeats 

## _0 _________ _ MUST CHECK ONE 

# 0 More than 50% of the above-described aircraftwas built from miscellaneous parts and I am the 

## ovmer. (This option is for aircraft eligible for amateur-built certification.) 

# 0 More than 50% ofthe above-described aircraftwas builtfrom 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.} [{] 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.) 

# 0 Evidence of 0\vnership from the aircraft builder through any inte!Vening owners is attached (chain ofownership). 

# 0 Unable to obtain complete chain ofownership. Statement as to ownership history and whereabouts of aircraft Is attached. 

### NameofOwner: 

## D&C lnsP,ection Services Title ofSigner (IfAppropriate): 

## _P_r_e_s_id_e_n_t____ _ SignatureofOwner: Address: City: 

## Seabrook Telephone: 

## 281-326-1800 Notmy Public: State of: Subscribed and swom to 

### before me this State: 

## TX
**---~~~--**



### County of: 

# Hards _;;y-\'li,

**~** 

### dayof My Conu.nission



## ~xfire:: __ 

# 6

**3~**

# /lf- ,-:;z

# 0{1



# fi~ 

# 111 c

# t£1cl (Signature ofNotaryPublic) 

## I

ACForm 8050-88 (03/12) Zip: 

## 77586