OMB Control No. 2120·0042 

Exp.11130/2014 

Paperwork Reduction Act Statement: The infonnation 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. OMS 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. ATTN: 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 

Name of Amateur /Non TC'd builder OJ I Innovations -----------------------------------------

Model S1000 Serial Number PH696150044 

Class (airplane, rotorcraft, glider, weight shift 

control, powered-parachute, etc.) Rotorcraft 

Type of Engine Installed (reciprocating, turboprop, 2 or 4 cycle, electric, etc.) Electric 

Manufacturer, Model and Serial Number of each Engine Installed ~D_J_I_In_n_o_v_a_t_io_n_s _________ _ 

Model: 4114 Pro KD400 S/N: N/A Number of Engines ltlStalled _8 _______ _ 

Built for Land or Sea Operation _L_a_n_d __________ Number of Seats _0 _________ _ 

MUST CHECK ONE 

0 More than 50% of the above-described aircraft was built from miscellaneous parts and I am the ovmer. (This option is for aircraft 

eligible for amateur-built certification.) 

0 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.} 

[{] 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 of ownership). 

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

Name of Owner: D&C lnsP,ection Services 

Title of Signer 

(If Appropriate): _P_r_e_s_id_e_n_t ____ _ Signature of Owner: 

Address: 

City: Seabrook 

Telephone: 281-326-1800 

Notmy Public: 

State of: 

Subscribed and swom to before me this 

State: TX 

---~~~--

County of: Hard s 

_;;y-\'li, 

~ dayof 

My Conu.nission ~xfire:: __ 6 3~ /lf- ,-:;z 0{1 

fi~ 111 c t£1cl 

(Signature ofNotary Public) I 

AC Form 8050-88 (03/12) 

Zip: 77586