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CLAIM No.

DATE OF CLAIM

AIRCRAFT

MSN (Manufacturers Serial Number):

A/C REG (Aircraft Registration Number):

TR S/N (Thrust Reverser Serial Number):

A/C FH (Flight Hours):

A/C FC (Flight Cycles):

Eng SN (Engine Serial Number):

PART CLAIM #1

COMPENSATION TYPE: *

FOC (Free of Charge) Part

Credit Note

PART NO. *

SERIAL NO. *

DEFECT *

DATE OF REMOVAL/REPLACEMENT *

PART FLIGHT HOURS

PART FLIGHT CYCLES

PART COST $

LABOR HOURS

LABOR RATE/HR $

CLAIMED LABOR COST $

OTHER COST CLAIMED $

OTHER COST CLAIMED DETAILS

TOTAL AMOUNT CLAIMED $

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ADD PART CLAIM No. 2

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PART CLAIM #2

COMPENSATION TYPE: *

FOC (Free of Charge) Part

Credit Note

PART NO. *

SERIAL NO. *

DEFECT *

DATE OF REMOVAL/REPLACEMENT *

PART FLIGHT HOURS

PART FLIGHT CYCLES

PART COST $

LABOR HOURS

LABOR RATE/HR $

CLAIMED LABOR COST $

OTHER COST CLAIMED $

OTHER COST CLAIMED DETAILS

TOTAL AMOUNT CLAIMED $

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ADD PART CLAIM No.3

Check to add another part claim

PART CLAIM #3

COMPENSATION TYPE: *

FOC (Free of Charge) Part

Credit Note

PART NO. *

SERIAL NO. *

DEFECT *

DATE OF REMOVAL/REPLACEMENT *

PART FLIGHT HOURS

PART FLIGHT CYCLES

PART COST $

LABOR HOURS

LABOR RATE/HR $

CLAIMED LABOR COST $

OTHER COST CLAIMED $

OTHER COST CLAIMED DETAILS

TOTAL AMOUNT CLAIMED $

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