October 28, 1995 Mobil AV-1 Claim Form

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by	The Editors of AVweb

Complete Coverage from AVweb (Links to Related Articles) Primary Coverage Mobil AV-1 Under Attack Settlement Reached in Mobil AV-1 Class-Action Lawsuit Mobil's Handling of AV-1 Claims Questioned Supplemental Articles Mobil AV-1 Engine Inspection and Repair Protocol Mobil AV-1 Notice of Settlement Press Release: Mobil AV-1 Settlement Mobil AV-1 Claim Form

The Mobil AV-1 Claim Form must be fully completed and returned to the address noted below in order to commenence processing your entitlement pursuant to the Inspection Protocol.

To participate in the settlement, the Mobil AV-1 Claim Form must be returned no later than three months from the entry of order granting final approval to the settlement.

You must provide a copy of your current registration and Certificate of Airworthiness with this form.

Registered Owner of Aircraft:

• Last Name

• First Name

• Corporate Owner of Aircraft (Name of Corporation)

• Street Address

• City

• State

• Zip

• Telephone, Home

• Telephone, Work

• Facsimile

• Social Security No

• Tax ID No

Contact Person (if different from Registered Owner of Aircraft):

• Last Name

• First Name

• Street Address

• City

• State

• Zip

• Telephone, Home

• Telephone, Work

• Facsimile

Location at which aircraft is normally hangered:

• Name of Facility

• Street Address

• City

• State

• Zip

Aircraft:

• Aircraft Make

• Aircraft Model

• Aircraft Serial Number

• "N" Number

Engine:

• Engine Model

• Engine Serial Number(s)

  • (R)

  • (L)

• Total Time (TT)

  • (R)

  • (L)

• Time Since Overhaul (TSOH)/Rebuild

  • (R)

  • (L)

Primary Mechanic/FBO:

• Name

• Street Address

• City

• State

• Zip

• Telephone

• Date of Last Service

Engine Oil History:

• Total Hours Mobil AV-1 used

• Has your engine been completely rebuilt or completely overhauled since discontinuing use of AV-1?

  • Yes

  • No

• Oil Drain Intervals while using AV-1 (ODI)

  •  

  •  

  •  

• Oil Filter Intervals while using AV-1 (OFI)

  •  

  •  

  •  

• Other oils used in your aircraft and total timc of each

Compression History:

• When was the engine compression last checked?

• Who performed the compression check?

• Street Address of person who performed last compression test (if different from mechanic listed above)

• City

• Telephone

• State

• Zip

• Date of Check

• What were the results of the last compression check?

  1. _____/80

  2. _____/80

  3. _____/80

  4. _____/80

  5. _____/80

  6. _____/80

• Have you experienced any variation in oil consumption?

  • Yes

  • No

• Has your rate of oil consumption declined?

  • Yes

  • No

• Has your rate of oil consumption dramatically increased? [Meaning a sustained trend line with a doubling of oil consumption of 150+ hours] (If yes, enclose copies of documentation.)

  • Yes

  • No

Propeller History:

• Have you experienced propeller problems

  • Yes

  • No

• Have you experienced propeller sluggishness

  • Yes

  • No

• Have you experienc4rd propeller overspeed

  • Yes

  • No

• Have you been able to reach and maintain desired propeller RPM?

  • Yes

  • No

Oil and Filter Analysis History:

• Have you performed any used oil analysis on this engine? (If so, please attach original test results)

  • Yes

  • No

• When was the engine oil filter last inspected?

• Where was the engine oil filter last inspected?

• Describe the results

Operator:

• Name of Individual or Organization

• Address

• City

• State

• Zip

Use History:

• Primary use of aircraft?

  • Business

  • Pleasure

• Approximate number of hours the aircraft was flown during the preceding one year

• Has your engine already been repaired at Mobil expense?

  • Yes

  • No

Past Repairs:

• Have repairs been performed on your engine which you believe werc related to AV-1?

  • Yes

  • No

  • I don't know

• If Yes, were they:

  • Top End

  • Bottom End

  • I don't know

• Please attach copies of all maintenance records, work orders and receipts showing work done which you believe may be related to AV-1.

Loss-Of-Use:

For any repairs identified above which you believe may be attributable to past AV-1 use, please state period of time during which your aircraft was unable to fly as a result of the need to make such repairs (e.g., number of days airplane was in the mechanic shop):

• From date

• To date

I declare under penalty of perjury that to the best of my knowledge and belief the foregoing information is true and correct.

• Dated

• Signature

Upon our receipt of your completed Mobil AV-1 Claim Form, you will be contacted by a Designated Mobil Representative regarding your entitlement to benefits pursuant to the terms of the Inspection Protocol, The Claim Form must be completed before we can begin to consider your entitlement.

Please mail the completed form to:

MOBIL AV-1 PROGRAM
P.O. BOX 450429
ATLANTA, GEORGIA 31145

AUTHORIZATION

I, ______________________, (Name), the owner of a __________________ (Model of Aircraft) containing a __________________ (Engine Model) engine(s), serial number(s) __________________ hereby authorize all aircraft maintenance or overhaul facilities or persons maintaining records concerning the maintenance and/or repair of the subject engine or propeller, to release all said records to Mobil Corporation or their designated representative upon their request. A copy of this authorization shall have the same force and effect as the original.

• Dated:

• Signature: