GENERAL DECLARATION

(Outward/Inward)

Owner/Company: ELKHORN AVIATION, LLC Flight

Phone & Fax: No. T123108

Marks of Nationality
and Registration: N380AC Date: 12/14/2008

Departure from: CHINO, UNITED STATES Arrival at: BELIZE, BELIZE

FLIGHT ROUTING
CHINO BELIZE

CREW DOB Nation Sex Passport# Expires Visa Expires

CAPT: METZ, HARRY 09/30/58 US M 201863509 02/06/10

F/O: GOOD, BRIAN 03/11/63 US M 500352424 10/11/16
ADDL: SCHWARTZ, STEPHANIE 03/05/08 US F 302370283 10/15/12

PASSENGER

1. RIETH, ROBERT PETER 07/13/1959 US M 203936815 10/31/10

2. LEE, HEY KYUNG 02/21/1969 KORE F LA0320460 07/14/11
3. KIM, YOO SEUNG 03/16/1966 US M 212043627 11/04/14
4. CHOI, IK JUNG 12/03/1962 KORE M LA0294521 11/19/09
5. CHOI, SERENA 08/16/1968 US F 206345593 04/22/12
6. KIM, EUGENE DUK JOON 01/11/1963 US M 222747114 05/23/17
7. AHN, DANINIEL DONG-HYUN 09/02/1966 US M 208731534 07/14/13
8. LEE, KYONG HOON 02/28/1960 KORE M SC1435165 01/18/16

DECLARATION OF HEALTH For Official Use Only

Persons on board known to be suffering from illness
other than airsickness or the effects of accidents, as
well as those cases of illness disembarked during the
flight.

Any other conditions on board which may lead to the

spread of disease.
Details of each disinfecting or sanitary treatment
(place, date, time, method) during the flight. If no
disinfecting has been carried out during the flight
give details of most recent disinfecting.

Signed
(Crew member concerned)

I declare that all statements and particulars contained in this General Declaration, and in any supplementary forms required to be presented with this
General Declaration are complete, exact and true to the best of my knowledge and that all through passengers will continue/have continued on the flight.

SIGNATURE
(Authorized Agent or Pilot-in-Command)

(1) To be completed when required by the state.

(2) Not to be completed when passenger manifests are presented and to be completed only when required by the State.