"I certify that this aircraft, RV-12, S/N 120436, was built with materials and instructions provided by Vans Aircraft Inc. I have inspected it and consider it eligible for an Experimental Airworthiness Certificate for the purpose of Operating Light-Sport Aircraft under the provisions of 14 CFR part 21.191(i)(2)."
Signed:_______________________________ Date:_______________
Exact wording is not critical.