### OMB Control No. 2120-0042 Exp. 11/30/2014 Paperwork Reduction Act Statement: The information collected on this fonn is necessary to ensure applicant eligibility. The information is used to determine that the applicant meets the necessary qualifications as 

### omerof an amateur built aircraft. We estimate that itwill take approximately 30 minutes to complete the form. The Information collection is required to obtain abenefit. 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 of information unless 

### it dfsplays a currently valid OMB control number. OMB 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. 

### AFFIDAVIT OF OWNERSHIP FORAMATEUR-BUILT AND OTHER NON-TYPE CERTIFICATEDAIRCRAFT (does not includelight-sport) 

### U.S. Identification Name ofAmateur/Non TC'dbuilder 

## OJI Innovations 

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

## Phantom 2Vision Class (airplane, rotorcraft, glider, weight shift control, powered-parachute, etc.) 

### SerialNumber 

## PH636149022 

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

## Electric lvlanufacturer, Model and Serial Number ofeach EngineInstalled 

## _D_J_I_ln_n_o_v_a_t_io_n_s __________ _

_ M_o_d_e_I:_N_I_A_S_/_N_: _N_/_A ___________ NumberofEngines Installed 

## _4 ______ _ Built for Land orSea Operation 

## _L_a_n_d __________ Number ofSeats 

## _0 _________ _ MUST CHECKONE 

# O More than 50% ofthe 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% ofthe above-described aircraftwas built from a kit (prefabricated parts) and I am the ovmer. 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.) 

# 0 Evidence ofownership from the aircraft builder through any intervening owners is attached (chain ofovmership). 

# 0 Unable to obtain complete chain ofownership. Statement as to ownership history and whereabouts ofaircraft is attached. 

### NameofOwner: 

## D&C Inspection Services SignatureofOwner: 

### Title ofSigner


## M,..t......p't;:'s=X:.W~.L~;:kJ=!.i'l&lhj- (IfAppropriate): 

## _P_r_e_si_d_e_n_t____ _ Address: city: 

## Seabrook Telephone: 

## 281-326-1800 NotaryPublic: State of: Subscribedand sworn to before me this My Commission Expires: 

### (Signature ofNotmyPublic)

AC Form 8050-88 (03/12) State: 

## TX 

# ------ Zip: 

## 77586



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