Authorized Release Certificate Airworthiness Approval Tag {FAA 8130-3}

1. Approving Civil Aviation Authority/Country: 2. 3. Form Tracking Number: FAA/United States 4. Organization Name and Address: AUTHORIZED RELEASE CERTIFICATE FAA Form 8130­3, AIRWORTHINESS APPROVAL TAG 5. Work Order/Contract/Invoice Number: 8. Part Number: 9. Quantity: 10. Serial Number: 11. Status/Work: 6. Item: 7. Description: 12. Remarks: 13a. Certifies the items identified above were manufactured in conformity to: Approved design data and are in a condition for safe operation. Non-approved design data specified in Block 12. 13b. Authorized Signature: 13c. Approval/Authorization No.: 14a. 14 CFR 43.9 Return to Service Other regulation specified in Block 12 Certifies that unless otherwise specified in Block 12, the work identified in Block 11 and described in Block 12 was accomplished in accordance with Title 14, Code of Federal Regulations, part 43 and in respect to that work, the items are approved for return to service. 14b. Authorized Signature: 14c. Approval/Certificate No.: 13d. Name (Typed or Printed): 13e. Date (dd/mmm/yyyy): 14d. Name (Typed or Printed): 14e. Date (dd/mmm/yyyy): User/Installer Responsibilities It is important to understand that the existence of this document alone does not automatically constitute authority to install the aircraft engine/propeller/article. Where the user/installer performs work in accordance with the national regulations of an airworthiness authority different than the airworthiness authority of the country specified in Block 1, it is essential that the user/installer ensures that his/her airworthiness authority accepts aircraft engine(s)/propeller(s)/article(s) from the airworthiness authority of the country specified in Block 1. Statements in Blocks 13a and 14a do not constitute installation certification. In all cases, aircraft maintenance records must contain an installation certification issued in accordance with the national regulations by the user/installer before the aircraft may be flown. FAA Form 8130­3 (02­14) NSN: 0052-00-012-9005 American LegalNet, Inc. www.FormsWorkFlow.com