APPENDIX 4. SAMPLE DOCUMENTATION OF TECHNICAL
STANDARDS COMMITTEE FINDINGS

     (INSTRUCTIONS: Complete all blanks; Insert N/A in blanks not applicable to
       this particular review; check off other applicable items () as provided.)

ISSUED TO: _______________________  	ULTRALIGHT MAKE/MODEL: ______________________
ADDRESS:   _______________________   	SERIAL NUMBER:	            ______________________
                     _______________________  	REGISTRATION NUMBER:       ______________________

ENGINE MAKE/MODEL: ____________  	PROPELLER MAKE/MODEL:  _______________________
ENGINE MANUFACTURER'S                   	PROPELLER DIAMETER:        _______________________
 RATED HORSEPOWER: ____________  	PROPELLER PITCH:                 _______________________
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  FUEL CAPACITY: fuselage tank ________   wing tank _______    other _______    TOTAL: _________
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  GROSS EMPTY WEIGHT ........................................……………………………………....... _________
    -Exclusion for parachute system weight .....………………....... ________
      ( ) hand-deployed
      ( ) ballistically deployed
      ( ) installed and operational
      ( ) standard allowance weight given
      ( ) parachute system weighed separately
    -Exclusion for floats .....................…………………………...... ________
      ( ) weighed in landplane configuration only
      ( ) weighed in floatplane configuration only
      ( ) standard allowance for floats-only given
      ( ) standard allowance for amphib floats given
      ( ) standard allowance for amphib fuselage given
      ( ) standard allowance for outrigger floats given
      ( ) all floats weighed separately
            FLOAT MAKE/MODEL: ________________________
    -Fuel on board at weighing ..................……………………...... ________
  TOTAL WEIGHT ALLOWANCES .....................…………...... ________
  NET EMPTY WEIGHT (minus weight allowances) ......……………………………….........….. ________
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  MAXIMUM FULL-POWER LEVEL FLIGHT SPEED (calculated by AC 103-7, Appendix 1).  ________
   ( ) engine manufacturer maximum rated horsepower used
   ( ) derated horsepower of engine = ________. per engine manufacturer's specs
  DEMONSTRATED MAXIMUM FULL-POWER LEVEL FLIGHT SPEED ………................. ________
   ( ) timed (average of a series of three level runs in both directions)
   ( ) radar gun (average series of level runs per timed instructions)
   ( ) speed adjusted to sea level conditions
   ( ) artificial restriction ( ) power  ( ) propeller  ( ) aerodynamic
  DESCRIPTION OF RESTRICTION (should be included on the back of this form in
   sufficient written and graphic detail for an FAA inspector or other qualified
   person to ascertain that the restriction is in place and operational)
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  MAXIMUM POWER-OFF STALL SPEED (calculated by AC 103-7, Appendix 2) .………….. ________
    operating weight used = ________  maximum coefficient of lift used = ________
  DEMONSTRATED POWER-OFF STALL SPEED .........................………………………....... ________
       ( ) average of six or more stalls (in level flight, with an airspeed
       reduction of approximately one knot per second until stall occurs)
       ( ) high lift devices installed  ( ) flaps  ( ) slots  ( ) other

 CONFIGURATION:
   ( ) provisions for one occupant only
         ( ) seat width 22 inches or less (inside measurement)
         ( ) single seatbelt/shoulder harness
         ( ) single controls located logically for a person
             sitting in the center of the seat
   ( ) no equipment  is installed which could logically be construed as for a purpose
       other than sport/recreation of the operator, such as:
         ( ) towing hitches
         ( ) agricultural equipment
         ( ) advertisement on the wings
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 AIRWORTHINESS CERTIFICATION:
   ( ) no U.S. or foreign airworthiness certificate is currently Issued to this
       particular ultralight unit
   ( ) this ultralight has not been registered with the U.S. federal government.
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 LIST OF INSTALLED INSTRUMENTS AND EQUIPMENT:

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 OTHER:

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 ISSUED BY:

  ( ) A & P Mechanic; Name ______________________________ Certificate Number ________________

  ( ) Technical Standards Committee: Names: _________________________________________________
                                             		__________________________________________________
                                            		__________________________________________________

  ( ) National pilot organization recognizing this committee: ______________________________________
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 DATE OF ISSUANCE OF THIS DOCUMENT:  ________________________