Transcription of DD Form 365-4, Weight and Balance Clearance …
1 Weight AND Balance Clearance FORM F - TRANSPORT(Use reverse for tactical missions)FOR USE WITH 1-1B-40, NAVAIR01-1B-40, AND TM-55-1500-342-23 Form ApprovedOMB No. 0704-0188 DATE (YYYYMMDD) MISSION AIRCRAFT TYPE SERIAL NO. FROM TO HOME STATION PILOT REMARKSREF123456789101112 ITEMBASIC AIRCRAFT (From Chart C)CREW (No.)CREW'S BAGGAGESTEWARD'S EQUIPMENTEMERGENCY EQUIPMENTEXTRA EQUIPMENTOPERATING WEIGHTTAKEOFF FUEL ( Gal.)WATER AIRCRAFT WEIGHTWEIGHTINDEX ORMOM/LOAD ADJUSTER NUMBER CORRECTION/MOST FWD/MOST AFT 13 DISTRIBUTION OF ALLOWABLE LOAD (PAYLOAD) 14 ZERO FUEL WT ZERO FUEL WT INDEX OR MOM ZERO FUEL % (+ or -)INDEX WEIGHTREMOVEDTOTAL WEIGHTADDEDNET DIFFERENCELIMITATIONSCONDITIONTAKEOFFLAN DING1 FUELALLOWABLE GROSS WEIGHTTOTAL AIRCRAFT WT.
2 (Ref. 12)(Ref. 9) + (Ref. 23)OPERATING WT. (Ref. 9)ALLOWABLE LOAD (Ref. 13)(use smallest figure)1 Zero Fuel or Limiting Wing FuelPERMISSIBLE FUEL BYSIGNATUREWEIGHT AND BALANCEAUTHORITY SIGNATUREPILOT SIGNATURE1516171819202122232425 TAKEOFF CONDITION (Uncorrected)TAKEOFF IN % OR INCORRECTIONS (If required)TAKEOFF CONDITION (Corrected)TAKEOFF IN % OR INZERO FUEL WT (Ref. 14)LESS AIR DROP LOADESTIMATED LANDING FUELESTIMATED LANDING CONDITIONESTIMATED LANDING IN % OR INDD FORM 365-4, AUG 96 PREVIOUS EDITION MAY BE public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing datasources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
3 Send comments regarding this burden estimate or any other aspectof this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents shouldbe aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control DO NOT RETURN YOUR FORM TO THE ABOVE FORM 365-4 (BACK), AUG 96 Weight AND Balance Clearance FORM F - TACTICAL(Use reverse for transport missions)FOR USE WITH 1-1B-40, NAVAIR 01-1B-40, AND TM-55-1500-342-23 DATE (YYYYMMDD) MISSION AIRCRAFT TYPE SERIAL NO.
4 FROM TO HOME STATION PILOT CORRECTION/MOST FWD/MOST AFT (Ref. 11) COMPTITEMCHANGES (+ or -)INDEX ORMOM/ Weight +_+_TOTAL Weight ADDEDTOTAL Weight REMOVEDNET DIFFERENCE (Ref. 11)REMARKSREF123 ITEMWEIGHTINDEX OR MOM/BASIC AIRCRAFT (From Chart C) WEIGHTMISC. VARIABLESTAKEOFF CONDITION (Uncorrected)TAKEOFF IN % OR INCORRECTIONS (If required)TAKEOFF CONDITION (Corrected)TAKEOFF IN % OR INTAKEOFF FUELESTIMATED LANDING FUELESTIMATED LANDING CONDITION5 AMMOBOMB S,MISSILE S,ET LANDING IN % OR INLIMITATIONSCOMPUTED BY SIGNATUREWEIGHT AND Balance AUTHORITY SIGNATUREPILOT SIGNATUREGROSS Weight TAKEOFF (lb.)GROSS Weight LANDING (lb.)PERMISSIBLE (% or in.) FORWARDAFTPERMISSIBLE (% or in.) FORWARDAFT
