1.

Approving National Aviation Authority /Country

2. 3. Form Tracking No:

AUTHORISED RELEASE CERTIFICATE

CASA FORM 1
4. Organisation Name and Address: 5. Work Order/ Contract/ Invoice
Number:

6. Item 7. Description 8. Part Number 9. Quantity 10. Serial No. 11. Status/Work

12. Remarks:
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………….

13a. Certifies that the items listed above were manufactured in conformity to: 14a. Division 42.H.4 of CASR 1998 - Certificate of Release to Service (CASR Part 145 AMO)

Approved design data and in a condition for safe operation; or Regulation 42WA of CAR 1988 - Return to Service (for Part 4A maintenance under CAR 1988)

Non-approved design data specified in Block 12.
13b. Authorised Signature:
13c. CASA Approval No:
Other regulations specified in Block 12
Certifies that unless otherwise specified in Block 12, the work identified in Block 11 and described in
Block 12 was carried out in accordance with Civil Aviation Safety Regulations, 1988 & 1998 and in
respect to that work, the items are approved for return to service.
14b. Authorised Signature: 14c. CASA Certificate No:

……………………………………………………………… ………………………………………………………
13d. Name: (printed or typed) 13e. Date: (dd/mmm/yyyy) 14d. Name: (printed or typed) 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 part/component/assembly. Where the user/installer works in
accordance with the national regulations of a National Aviation Authority (NAA) different than the NAA of the country specified in Block 1 it is essential that the user/installer ensures that
his/her NAA accepts parts, components, assemblies from the NAA of the country specified in Block 1. Statements in Block 13a and 14a do not constitute installation certification. In all cases
the aircraft maintenance record must contain an installation certification issued in accordance with the national regulations by the user/installer before the aircraft may be flown.

Form 001 03/2014 Authorised Release Certificate Page 1 of 1

1. País (Country) 2. Título (Title) 3. Certificado Nº
(Certificate No./System Tracking Ref.)
AGÊNCIA NACIONAL DE AVIAÇÃO CIVIL (BRAZILIAN CIVIL AVIATION AUTHORITY)
BRASIL CERTIFICADO DE LIBERAÇÃO AUTORIZADA (AUTHORIZED RELEASE CERTIFICATE)
ETIQUETA DE APROVAÇÃO DE AERONAVEGABILIDADE (AIRWORTHINESS APPROVAL TAG)
Formulário (Form) F-100-01 (SEGVOO 003)
4. Empresa (nome e endereço) 5. Ordem Serviço/ Contrato / Nota
(Organization Name and Address) Fiscal
(Work Order, Contract or Invoice)

6. Item 7. Descrição 8. Número da Peça 9. Quantidade 10. Número de Série / Lote 11. Categoria / Trabalho
(Item) (Description) (Part Number) (Quantity) (Serial / Batch Number) (Status / Work)

12. Observações
(Remarks)

Partes com vida limitada devem ser acompanhadas de histórico de manutenção incluindo tempo total / ciclo total / tempo desde que novo. (Limited life parts must be accompanied by maintenance history including total time/total cycles/times since new)

13. Certifica que o(s) item(ns) acima identificado(s) foi (foram) fabricado(s) em conformidade aos: 18. Retorno ao serviço de acordo com RBAC 43.9 Outros regulamentos especificados no bloco 12
(Certifies that the item(s) identified above was (were) manufactured in conformity to: ) (Return to service in accordance with RBAC 43.9) (Other regulations specified in block 12)

dados de projeto aprovados e está(ão) em condição segura de operação Certifica que, a menos do especificado no bloco 12, o trabalho especificado no bloco 11 e descrito no bloco 12 foi executado de acordo
(approved design data and are in a condition for safe operation) com o Regulamento Brasileiro da Aviação Civil - RBAC 43 e, em relação ao trabalho realizado, a(s) peça(s) é (são) aprovada(s) para
retorno ao serviço.
dados de projeto não aprovado especificados no bloco 12
(non-approved design data 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
Brazilian Civil Aviation Regulations - RBAC 43 and in respect to the work performed the part(s) is (are) approved for return to service.)

14. Assinatura do Representante da ANAC - (ANAC Representative Signature). 15. Nº Autorização da ANAC (ANAC Authorization No.) 19. Pessoa Autorizada (Authorized Signature) 20. Nº COM/COA - (Certificate Number)

16. Nome (Name) 17. Data (Date) 21. Nome (Name) 22. Data (Date)

* O INSTALADOR DEVE FAZER VERIFICAÇÃO CRUZADA DA APLICABILIDADE ATRAVÉS DOS DADOS TÉCNICOS APLICÁVEIS. (INSTALLER MUST CROSS CHECK ELIGIBILITY WITH APPLICABLE TECHNICAL DATA)

RESPONSABILIDADE DO USUÁRIO / INSTALADOR (USER / INSTALLER RESPONSIBILITY)

É IMPORTANTE COMPREENDER QUE A EXISTÊNCIA DESTE DOCUMENTO POR SI SÓ NÃO CONSTITUI AUTOMATICAMENTE UMA AUTORIZAÇÃO
PARA INSTALAR A PARTE / COMPONENTE / CONJUNTO.
SE O TRABALHO DO USUÁRIO/INSTALADOR É REALIZADO DE ACORDO COM OS REGULAMENTOS NACIONAIS DE UMA AUTORIDADE DE
AERONAVEGABILIDADE DIFERENTE DA AUTORIDADE DE AERONAVEGABILIDADE DO PAÍS ESPECIFICADO NO BLOCO 1, É ESSENCIAL QUE O
USUÁRIO/INSTALADOR ASSEGURE QUE A SUA AUTORIDADE DE AERONAVEGABILIDADE ACEITA PARTES/COMPONENTES/CONJUNTOS DA
AUTORIDADE DE AERONAVEGABILIDADE DO PAÍS ESPECIFICADO NO BLOCO 1.
AS DECLARAÇÕES NOS BLOCOS 13 E 18 NÃO CONSTITUEM UM CERTIFICADO DE INSTALAÇÃO. EM TODOS OS CASOS, OS REGISTROS DE
MANUTENÇÃO DA AERONAVE DEVEM CONTER UM CERTIFICADO DE INSTALAÇÃO EMITIDO DE ACORDO COM REGULAMENTOS NACIONAIS
PELO USUÁRIO/INSTALADOR ANTES QUE A AERONAVE POSSA SER LIBERADA PARA VOO.
(IT IS IMPORTANT TO UNDERSTAND THAT THE EXISTENCE OF THIS DOCUMENT ALONE DOES NOT AUTOMATICALLY CONSTITUTE AUTHORITH
TO INSTALL THE PART / COMPONENT / ASSEMBLY).
(WHERE THE USER / INSTALLER WORK IS PERFORMED 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 PARTS/COMPONENTS/ASSEMBLIES FROM THE
AIRWORTHINESS AUTHORITY OF THE COUNTRY SPECIFIED IN BLOCK 1).
(STATEMENTS IN BLOCK 13 AND 18 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).

F-100-01C (10.16)
Figure 1 - Authorized Release Certificate

1. Approving national aviation authority/country 2. 3. Form tracking No.

AUTHORIZED RELEASE CERTIFICATE
Transport Canada TCCA 24-0078
4. Approved organization name and address 5. Work order/contract/invoice

6. Item 7. Description 8. Part No. 9. Eligibility* 10. Qty. 11. Serial/batch No. 12. Status/work

13. Remarks

14. Certifies that the items identified above were manufactured in conformity to: 19.

CAR 571.10 Maintenance release.

Approved design data and are in condition for safe operation.

Other regulations specified in block 13.

Non approved design data specified in block 13.
Certifies that, except where otherwise specified in block 13, the work identified in
block 12 and described in block 13 was performed in accordance with CAR 571.

15. Authorized signature 16. Certificate/Approval ref. No. 20. Authorized signature 21. Certificate/Approval ref. No.

17. Name 18. Date (dd/mmm/yyyy) 22. Name 23. Date (dd/mmm/yyyy)

12/09/2001 *Installer must cross-check eligibility with approved data

Civil Aircraft Maintenance Organization Certification Regulations (CAAC Decree No.152)

Attachment 7-Authorized Release Certificate/Airworthiness Approval Tag [Form AAC-038(12/94)]

AUTHORIZED RELEASE CERTIFICATE/AIRWORTHINESS APPROVAL TAG

AAC-038(12/94) *
Cross-check eligibility for more details with parts catalogue

CCAR-145-R3 - 65 -
1. Approving Civil Aviation 2. 3. Form Tracking Number:
Authority/Country: 00000000000004352
FAA/United States AUTHORIZED RELEASE CERTIFICATE
FAA Form 8130–3, AIRWORTHINESS APPROVAL TAG
4. Organization Name and Address: 5. Work Order/Contract/Invoice
Number:
Iberia airlines. Calle serrano, número 32 edificio azul. FAA REPAIR STATION CERTIFICATE NUMBER 69305K 34645765
6. Item: 7. Description: 8. Part Number: 9. Quantity: 10. Serial Number: 11. Status/Work:

01 Fire extinguisher bottle 76306-07901-103 1(one) 96351EJ REPLACEMENT/TESTED

12. Remarks:
The work hass been done in accordance with Iberia airlines.
AMM (Aircraft Maintenance Manual) 26-21-01
REFERENCE ORDER-RO34253464574
The piece is serviciable.
TESTS OK.
All system cheked following AMM, FIM (Fault Isolation Manual) and SSM (System Schematic Manual)

13a. Certifies the items identified above were manufactured in conformity to: 14a.
Approved design data and are in a condition for safe operation.
Non-approved design data specified in Block 12.
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.

13b. Authorized Signature: 13c. Approval/Authorization No.: 14b. Authorized Signature: 14c. Approval/Certificate No.:

729988A

13d. Name (Typed or Printed): 13e. Date (dd/mmm/yyyy): 14d. Name (Typed or Printed): 14e. Date (dd/mmm/yyyy):
ADALBERTO SÁNCHEZ SOLÓRZANO 26-Dec-2021
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 8130–3 (02–14) NSN: 0052-00-012-9005

 STATEMENT OF COMPLIANCE
1. 8110-3 Tracking Reference:

WITH AIRWORTHINESS REQUIREMENTS

PRODUCT APPLICABILITY
2. MAKE: 3. MODEL / PART Nº: 4. PRODUCT TYPE 5. CAA Part 146 Organisation:
(Aircraft, Engine,
Propeller, Component):
6. CAA Part 146 Client ID Nº:

LIST OF TECHNICAL DATA

7. IDENTIFICATION: 8. TITLE(S):

9. PURPOSE OF DATA:

10. APPLICABLE REQUIREMENTS (List specific sections):

11. CERTIFICATION:
This Statement of Compliance certifies that the technical data listed above has been examined in accordance with established
procedures of the specified Part 146 Design Organisation and found to comply with CAR 21.31 and the applicable airworthiness
requirements listed above.

12. SIGNATURE(S) of Part 146 Authorised Persons: 13. NAME: 14. DATE

Page 1 of 2 CAA 8110-3

Rev 0 : May 2016
 CAA FORM 8110-3 INSTRUCTIONS

Field No. and description:

1. Applicant generated unique identifier for the purpose of traceability of the completed form.

2-6. Self-explanatory

7. List the Data identifiers (Document #, Report #, Drawing # etc), and Revision Status. Descriptive Data and
Substantiating Data should be grouped separately. A document list such as a master data list may be used.

8. Data titles aligned with respective Data Identifiers in Field 7. If there are any exclusions to the compliance
certification, enter the exact extent of these exclusions below each data title. Descriptive Data and Substantiating
Data should be grouped separately.

9. General text describing the activity that the data supports e.g. “In support of TC Project XYZ”.

10. Enter the exact regulation(s) paragraphs, subparagraphs, or other appropriate airworthiness requirements with
which the data comply. This includes applicable amendment levels. If the list is too long, attach additional sheets.
A reference to another document may be acceptable.

11. Self-explanatory.

12. Only persons authorised by the Part 146 Organisation to sign Statements Of Compliance may sign this document.
When more than one authorised person is required to sign this Statement Of Compliance, each entry in the "List
of Technical Data" must clearly identify which aspects of the data each authorised person is signing for. This
distinction can be made entry by entry, or by grouping the entries for each authorised person. If entries in this
block cannot be clearly identified for each authorised person then separate Statements Of Compliance should be
used with only one signature on each.

13. Self-explanatory.

14. Each signatory is to enter the date they sign the Statement Of Compliance.

Page 2 of 2 CAA 8110-3

Rev 0 : May 2016
 AUTHORIZED RELEASE CERTIFICATE
1. Approving Civil Aviation 2. 3. Form Tracking Number:
Authority/Country:

GACA/Saudi Arabia AIRWORTHINESS APPROVAL TAG

4. Organization Name and Address: 5. Work Order/Contract/Invoice

Number:

6. Item: 7. Description: 8. Part Number: 9. Quantity: 10. Serial Number: 11. Status/Work:

12. Remarks:

13a. Certifies the items identified above were manufactured in conformity to: 14a. GACAR § 43.11 Other regulation specified in Block 12
Certifies that unless otherwise specified in Block 12, the work identified in Block 11
Approved design data and are in a condition for safe operation. and described in Block 12 was accomplished in accordance with GACAR Part 43
Non-approved design data specified in Block 12. and in respect to that work, the items are approved for
return to service.

13b. Authorized Signature: 13c. Approval/Authorization No.: 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.

SS&AT_AW_F8130-3_V1.0 (01-March-2016) Page 1 of 1

SECTION 2 APPENDIX 3 SAR-145

1. Country 2. CIVIL AVIATION AUTHORITY OF SINGAPORE 3. Form Tracking Number

SINGAPORE AUTHORISED RELEASE CERTIFICATE
CAAS(AW)95
4. Approved Organisation Name and Address 5. Work Order/Contract/Invoice

6. Item 7. Description 8. Part No. 9. Eligibility * 10. Quantity 11. Serial/Batch No. 12. Status/Work

13. Remarks

14. NEW PARTS 19. USED PARTS

Certifies that the items identified above were manufactured in conformity SAR-145.50 Release to Service
to: Other regulation specified in Block 13
Approved design data and are in condition for safe operation
Certifies that unless specified in Block 13, the work identified in Block 12
Non-approved design data specified in Block 13 and described in Block 13, was accomplished in accordance with SAR-
145 and the Air Navigation Order and in respect to that work the items
are considered ready for release to service.
15. Authorised Signature 16. CAAS Approval No. 20. Authorised Signature 21. CAAS Approval No.

17. Name 18. Date (d/m/y) 22. Name 23. Date (d/m/y)

CAAS(AW)95 - Issue 2 * Installer must cross check eligibility with applicable technical data

(Front)

USER / INSTALLER RESPONSIBILITIES

NOTE:

1. It is important to understand that the existence of the Certificate alone does not automatically constitute
authority to install the part/component/assembly.

2. Where the user/installer works in accordance with the national regulations of an Airworthiness Authority
different from the Civil Aviation Authority of Singapore (CAAS), it is essential that the user/installer ensures
that his/her Airworthiness Authority accepts parts/components/assemblies from the CAAS.

3. Statements 14 and 19 do not constitute installation certification. In all cases, the aircraft maintenance record
must contain an installation certification issued in accordance with the national regulations by the
user/installer before the aircraft may be flown.

(Reverse)

1 March 2017 2-40 First Issue, Amendment 13

1. Approving Competent Authority / Country 2. AUTHORISED RELEASE CERTIFICATE 3. Form Tracking Number
SHGM FORM 1
Turkish DGCA / Turkey

4. Organisation Name and Address: 5. Work Order/Contract/Invoice

6. Item 7. Description 8. Part No. 9. Qty. 10. Serial No. 11. Status/Work

12. Remarks

14a. Part-145.A.50 Release to Service Other regulation specified in block 12

13a. Certifies that the items identified above were manufactured in conformity to:
Certifies that unless otherwise specified in block 12, the work identified in block 11
approved design data and are in a condition for safe operation
and described in block 12, was accomplished in accordance with SHY-145 and in respect to
non-approved design data specified in block 12
that work the items are considered ready for release to service.
13b. Authorised Signature 13c. Approval/ Authorisation Number 14b. Authorised Signature 14c. Certificate/Approval Ref. No.

13d. Name 13e. Date (dd mmm yyyy) 14d. Name 14e. Date (dd mmm yyyy)

USER/INSTALLER RESPONSIBILITIES
This certificate does not automatically constitute authority to install the item(s).
Where the user/installer performs work in accordance with regulations of an airworthiness authority different than the airworthiness authority specified in block 1, it is essential that the
user/installer ensures that his/her airworthiness authority accepts items from the airworthiness authority 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.

Doküman No : SHGM.UED.26005653.FR.01 Revizyon No-Tarihi : 01/21.11.2013 1/1

 CAR 145

APPENDIX I
to CAR 145

1. General Civil Avia on Authority 2. AUTHORISED RELEASE CERTIFICATE 3. Form Tracking Number
United Arab Emirates
AW FORM 1
4. Organisa on Name and Address 5. Work Order/Contract/Invoice

6. Item 7. Descrip on 8. Part Number 9. Qty. 10. Serial Number 11. Status/Work

12. Remarks

13a. Cer es that the items iden ed above were manufactured in 14a. CAR 145.50 Release to Service Other regula on, speci ed in block 12
conformity to: Cer es that unless otherwise speci ed in block 12, the work iden ed in block
Approved design data and are in condi on for safe opera on 11 and described in block 12, was accomplished in accordance with CAR 145 and
Non-approved design data speci ed in block 12 in respect to that work the items are considered ready for release to service.

13b. Authorised Signature 13c. Approved/Authorised Number 14b. Authorised Signature 14c. Cer ed/Approved Ref. Number

13d. Name 13e. Date (dd mmm yyyy) 14d. Name 14e. Date (dd mmm yyyy)

USER/INSTALLER RESPONSIBILITIES
This cer cate does not automa cally cons tute authority to install the item(s).
Where the user/installer performs work in accordance with regula ons of an airworthiness authority di erent than the airworthiness authority speci ed in
block 1, it is essen al that the user/installer ensures his/her airworthiness authority accepts items from the airworthiness authority speci ed in block 1.
Statements in blocks 13a and 14a do not cons tute installa on cer ca on. In all cases aircra maintenance records must contain an installa on cer ca on
issued in accordance with the na onal regula ons by the user/installer before the aircra may be own.
Issue: 01 July 2011 Issue: 2

Issue: September 2011 Page 74 of 97