1. Request for Registration of a Declaration of Design Compliance (Part 21 Light Subpart C)

1.1 EASA Request No

6XXXXX

1.2 Date of Request for Registration

1.3 Applicability

Designated Type Name

(this must be a unique means to identify the aircraft)

Designated Model Name(s)

Important Note: Points 1.1. and 1.2. should be left blank when the Declaration of Design Compliance (EASA Form 200 – Part 2) is submitted together with the request for registration.

2. Design Compliance

2.1 Technical Specifications used for Compliance

Please specify the technical specifications used and the amendment/issue number (e.g. CS‑23 Amendment 6)

2.2 Environmental Protection Requirements

if applicable

Please specify the environmental protection requirements with which compliance has been determined

2.3 Engine Details

if applicable

 Engine has been issued with an EASA type certificate

Please provide the EASA type-certificate number and engine details

 Compliance of the engine with the applicable technical specifications (as detailed in 2.1 above) has been declared within this Declaration

2.4 Propeller Details

if applicable

 Propeller has been issued with an EASA type certificate

Please provide the EASA type-certificate number and propeller details

 Compliance of the propeller with the applicable technical specifications (as detailed in 2.1 above) has been declared within this Declaration

2.5 Compliance Demonstration Plan

Please specify the reference, revision number and date of the compliance demonstration plan

2.6 Documentation

in accordance with 21L.A.43 (b)

Documents/information to submit for registration of the Declaration:

· Airworthiness Data Sheet

· Aircraft Flight Manual including any limitations

· Instructions for Continued Airworthiness

· Any other conditions/limitations which the declarant wishes to declare

· EASA Noise Record Number

Important Note: The Declaration of Design Compliance for the aircraft described in point 1.3 must be submitted along with the documentation detailed in point 21L.A.43 (b) 8, 9, 10, 11 and 12 and 21L.A.43 (c) of Annex Ib to Regulation (EU) 748/2012.

The supporting documents to the Declaration of Design Compliance can be provided to the Agency using the EASA data repository and do not need to be physically attached to the Declaration of Design Compliance.

3. Declaration of Compliance

I declare that I have the legal capacity to submit this declaration to EASA and that all information provided in this Declaration form is correct and complete.

I hereby declare that the design of the aircraft identified in Section 1.3 is in compliance with the applicable detailed technical specifications detailed in Section 2.1 and the applicable environmental protection requirements detailed in Section 2.2 in accordance with the compliance demonstration plan detailed in Section 2.5.

 (in the case that the engine is not issued with an EASA type certificate) The engine that is included within the design of the aircraft is compliant with the applicable technical specifications detailed in Section 2.1.

 (in the case that the propeller is not issued with an EASA type certificate) The propeller that is included within the design of the aircraft is compliant with the applicable technical specifications detailed in Section 2.1.

I hereby declare that no features or characteristics have been identified that may make the aircraft unsafe or environmentally incompatible for the intended use.

I hereby commit to undertake the obligations of a Declarant of a Declaration of Design Compliance as detailed in point 21L.A.47 of Annex Ib (Part 21 Light) to Regulation (EU) No 748/2012.

I declare that I have provided the information required in Section 2.6, and that it is accurate and complete and indicated where it is not applicable.

Date/Location

Name

Signature

Important Note: EASA cannot accept Declarations without signature. Please make sure that you sign the Declaration.

This Declaration should be sent by email to:

[email protected]