Form PTO/SB/53 Reissue Application: Consent of Assignee; Statement of N

PTO/SB/53 (04-04)
Approved for use through 04/30/2007. OMB 0651-0033
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

REISSUE APPLICATION: CONSENT OF ASSIGNEE;
STATEMENT OF NON-ASSIGNMENT

Docket Number (Optional)

This is part of the application for a reissue patent based on the original patent identified below.
Name of Patentee(s)
Patent Number

Date Patent Issued

Title of Invention

1.

2.

Filed herein is a statement under 37 CFR 3.73(b). (Form PTO/SB/96)

Ownership of the patent is in the inventor(s), and no assignment of the patent is in effect.

One of boxes 1 or 2 above must be checked. If multiple assignees, complete this form for each assignee. If
box 2 is checked, skip the next entry and go directly to “Name of Assignee”.
The written consent of all assignees and inventors owning an undivided interest in the original
patent is included in this application for reissue.

The assignee(s) owning an undivided interest in said original patent is/are __________________________,
and the assignee(s) consents to the accompanying application for reissue.

Name of assignee/inventor (if not assigned)
Signature

Date

Typed or printed name and title of person signing for assignee (if assigned)

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ADDRESS. SEND TO: Commissioner for Patents, P.O. Box 1450, Alexandria, VA 22313-1450.

If you need assistance in completing the form, call 1-800-PTO-9199 and select option 2.