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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?
_____/80
_____/80
_____/80
_____/80
_____/80
_____/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: