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Project Information

RFC Number *

Project Number *

RFC Date

Applicant *

Company Name *

Installation Type *

Aircraft Information

📋 This information will be used in Forms 8100-1 and 8130-9

Make *

Model *

Serial Number *

Registration *

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Item / Nomenclature of Item Inspected *

Status *

Drawing/Document Reference

Revision / Date

Findings / Comments *

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Inspector Information

Inspector Name

ODA Number

Beginning Date

Ending Date

Tracking Number

ℹ️ Sheet numbering (e.g. "Sheet 1 of 2") is inserted automatically by Word and updates when the document is opened.

STIR Cover Page FAA Form 8110-26 — Page 1

Project No.

Date

Product

Make

Model

Serial Number

Registration

Serial Nos. Eligible

TC / Product Spec Data Sheet

Rev No.

Certification Basis

Applicant

Applicant Name

Address Line 1

Address Line 2

Modifier

Modifier Name

Address Line 1

Address Line 2

Description of Modifications

Attachments

Signature Dates

Inspection Conducted By — Date

Report Prepared By — Date

Administrative Data Page 3

Inspection Period — From

Inspection Period — To

C. Number of conformity inspections

B. Where Conducted (name & address)

Questions D – H

D. Were design changes needed to correct deficiencies?

E. Have all products/articles been properly recorded?

F. Does applicant have conformity records on file?

H. Is supplemental type approval recommended?

G. FAA Forms Submitted

FAA Form 8110-12

FAA Form 8130-6

FAA Form 337

FAA Form 8130-9 (317)

Remarks

TIA Comments Page 4

Numbered comments per Section 12 of the TIA. Add as many as needed.

Section Answers Pages 5 – 6 (Sections 2.0 – 9.0)

Statement of Conformity FAA Form 8130-9

FAA Project No.

Date

Section I – Aircraft

1. Make

2. Model

3. Serial No.

4. Registration No.

Section II – Engine

1. Make

2. Model

3. Serial No.

Section III – Propeller

1. Make

2. Hub Model

3. Blade Model

4. Hub Serial No.

5. Blade Serial No.

Section IV – Certification

"I hereby certify that:" — Statement

Certification Options (check all that apply)

A. I have complied with Section 21.33(a).

B. The aircraft described above, produced under type certificate only (14 CFR part 21 Subpart F), conforms to its type certificate, is in a condition for safe operation, and was flight checked on: (Date)

Flight Check Date

C. The engine or propeller described above, presented herewith for type certification, conforms to the type design.

D. The engine or propeller described above produced under type certificate only (14 CFR part 21 Subpart F), conforms to its type certificate and is in a condition for safe operation. The engine or, if applicable, the variable pitch propeller was subjected by the manufacturer to a final operational check on: (Date)

Operational Check Date

Deviations

Certifier Information

Title

Organization