Lessor Maintenance Contribution Claim Form

Airline/Customer Name Operated by Batik Air

Airline/Customer Contact Person Name : Yunus Dzulisnain/Juni Kartanto
Phone : +62816103237 , Fax : +622163860180
E‐mail : yunus@lionair.co.id/juni.kartanto@lionair.co.id
Contracted Aircraft Serial Number 39871 (AERCAP)
Contracted APU Serial Number P-11056
(originally fitted to Aircraft MSN 39871, PK-LDP)
Description of Maintenance Event Overhauled (#RO 1388031)
Maintenance Facility/Engine Shop Used Honeywell International Sdn Bhd
Removal Date 27 March 2022
Total Time & Cycles at Removal TSN : 8928 : 42 CSN : 7732
TSLSV : 5294 : 25 CSLSV : 4560
Amount Claimed (US$) $351,886.08
Bank Details for Payment Beneficiary Name: PT. Batik Air Indonesia
Bank Name: BNP Paribas
Bank Address: Sequis Tower, Level 28, Jl. Jend. Sudirman
Kav. 71, SCBD Lot 11B, Jakarta 10310
Account USD No. 04010-002383-00123
Swift code: BNPAIDJA

Supporting Documentation Provided (Tick as Appropriate)

Maintenance Facility/Engine Shop Detailed Invoice
Lessee’s Invoice
Engines & APUs
Statement of work: F337, 8130-3, JAA form 1.
TSN, CSN, TSLSV, CSLSV
LLP status (at all thrust ratings where applicable)
Back to birth traceability on all replaced LLP components
Shop findings/Teardown report
AD and SB status (Note : There is no AD due during this shop visit)
Test cell data/summary
Post Test Boroscope Results (*Not Required*)
Warranty Action (*Not Applicable*)
Any technical deviations with FAA 8110-3 approval for same (*Not Applicable*)
Airframe
Certificate of release to service
Airframe time and cycles, total and time to next D check
Details of routine/non routine work performed
AD and SB status report
Landing Gear
Statement of work: 8130-3, JAA form 1
LLP status with Back to Birth trace on all replaced LLP’s
AD & SB status report
Incoming/outgoing inspection reports, electrical, hydraulic and accessory.
Any technical deviations with FAA 8110-3 approval for same.
Evidence of Landing Gear installation on to aircraft