FAR 61.15 · Sample

Sample FAA 61.15 DUI/DWI Reporting Form

If you have had an alcohol-related motor-vehicle action, you are generally required by FAR 61.15(e) to notify the FAA in writing. The sample letter below shows the information the FAA asks for. Download the original file or use the form as a template.

Sample Notification Letter

Date: ____________________

Federal Aviation Administration
Civil Aviation Security Division, AMC-700
P. O. Box 25810
Oklahoma City, OK 73125

Dear Sir or Madam:

I submit the following information in compliance with Federal Aviation Regulation 61.15(e):

NAME: ____________________________________________
DATE OF BIRTH: ____________________
CERTIFICATE #: ____________________
ADDRESS: ________________________________________
____________________________________________ (City, State, Zip Code)
TYPE OF VIOLATION: ______________ (DUI, DWI, DWAI, Refusal to Test, etc.)
DATE OF ACTION: ____________________ (Date of Conviction or Administrative Action)
STATE HOLDING RECORD: ____________
STATEMENT AS TO WHETHER THE MOTOR-VEHICLE ACTION AROSE FROM THE SAME INCIDENT OR FROM A PREVIOUSLY REPORTED ACTION (i.e., is this action from the same incident, or was there more than one arrest — particularly within a three-year period?)

Your signature: ____________________

Optional Information

Driver’s license number: ______________
Social Security number: ______________
Telephone number(s): ______________

Notes & How to Submit

Important: This is a sample for reference only. Always verify the current requirements and address with the FAA before submitting, and confirm whether your situation is reportable under the current FAR 61.15.

A motor-vehicle action includes suspensions, cancellations, revocations or denials of a driver’s license, or a conviction for an alcohol-related offense.
You may print and mail the form, or submit it via fax to (405) 954-4989.
Submit it in a timely manner to meet your reporting responsibility.

Download the original Word form

Why Reporting Matters

Reporting requirements exist so the FAA can evaluate airmen qualifications. Alcohol-related motor-vehicle actions are treated seriously — see our alcohol & flying guide to understand the full impact of alcohol on a pilot certificate and career.