Form PTO/SB/04 Supplemental Declaration for Utility or Design Patent Ap

Doc Code:

PTO/SB/04 (05-08)
Approved for use through 09/30/2010. OMB 0651-0032
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.

SUPPLEMENTAL

DECLARATION FOR UTILITY

OR DESIGN

PATENT APPLICATION

(37 CFR 1.67)

Attorney Docket Number
First Named Inventor

COMPLETE IF KNOWN
Application Number
Filing Date
Art Unit
Examiner Name

I hereby declare that:
Each inventor’s residence, mailing address, and citizenship are as stated below next to their name.
I believe the inventor(s) named below to be the original and first inventor(s) of the subject matter which is claimed and for which a patent is
sought on the invention entitled:

(Title of the invention)

the specification of which
is attached hereto

OR
was filed on (MM/DD/YYYY)

Application Number

as United States Application Number or PCT International

and was amended on (MM/DD/YYYY)

I hereby declare that the subject matter of the
attached amendment
amendment filed on
the invention and was invented before the filing date of the original application, above identified for such invention.

was part of

I hereby state that I have reviewed and understand the contents of the above-identified specification, including the claims, as amended by any
amendment specifically referred to above.
I acknowledge the duty to disclose information which is material to patentability as defined in 37 CFR 1.56, including for continuation-in-part
applications, material information which became available between the filing date of the prior application and the national or PCT international
filing date of the continuation-in-part application.
I hereby claim foreign priority benefits under 35 U.S.C. 119(a)-(d) or (f), or 365(b) of any foreign application(s) for patent, inventor's or plant
breeder's rights certificate(s), or 365(a) of any PCT international application which designated at least one country other than the United
States of America, listed below and have also identified below, by checking the box, any foreign application for patent, inventor's or plant
breeder's rights certificate(s), or of any PCT international application having a filing date before that of the application on which priority is
claimed.
Prior Foreign Application
Country
Foreign Filing Date
Priority
Certified Copy Attached?
Number(s)
(MM/DD/YYYY)
Not Claimed
YES
NO

Additional foreign application numbers are listed on a supplemental priority data sheet PTO/SB/02B attached hereto.

[Page 1 of 2]

This collection of information is required by 35 U.S.C. 115 and 37 CFR 1.63. The information is required to obtain or retain a benefit by the public which is to file
(and by the USPTO to process) an application. Confidentiality is governed by 35 U.S.C. 122 and 37 CFR 1.11 and 1.14. This collection is estimated to take 21
minutes to complete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the individual
case. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden, should be sent to the Chief Information
Officer, U.S. Patent and Trademark Office, U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313-1450. DO NOT SEND FEES OR COMPLETED
FORMS TO THIS 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.

PTO/SB/04 (05-08)
Approved for use through 09/30/2010. OMB 0651-0032
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.

Doc Code:

SUPPLEMENTAL DECLARATION — UTILITY OR DESIGN PATENT APPLICATION
Direct all correspondence to:
OR
Name

The address associated with Customer Number:

Correspondence address below

Address
Address
City

ZIP

State

Country

Telephone

Email

WARNING:

Petitioner/applicant is cautioned to avoid submitting personal information in documents filed in a patent application that may
contribute to identity theft. Personal information such as social security numbers, bank account numbers, or credit card numbers
(other than a check or credit card authorization form PTO-2038 submitted for payment purposes) is never required by the
USPTO to support a petition or an application. If this type of personal information is included in documents submitted to the
USPTO, petitioners/applicants should consider redacting such personal information from the documents before submitting them
to the USPTO. Petitioner/applicant is advised that the record of a patent application is available to the public after publication of
the application (unless a non-publication request in compliance with 37 CFR 1.213(a) is made in the application) or issuance of a
patent. Furthermore, the record from an abandoned application may also be available to the public if the application is
referenced in a published application or an issued patent (see 37 CFR 1.14). Checks and credit card authorization forms PTO­
2038 submitted for payment purposes are not retained in the application file and therefore are not publicly available.
I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and
belief are believed to be true; and further that these statements were made with the knowledge that willful false statements and
the like so made are punishable by fine or imprisonment, or both, under 18 U.S.C. 1001 and that such willful false statements
may jeopardize the validity of the application or any patent issued thereon.
Name of Sole or First Inventor:

A petition has been filed for this unsigned inventor
Family Name or Surname

Given Name

Date

Inventor’s Signature
Residence: City

State

Country

Citizenship

Mailing Address
Mailing Address
City

State

ZIP

Country

Additional inventor(s) or legal representative(s) are being named on the _____ supplemental sheet(s) PTO/SB/ 02A or 02LR attached
hereto.
[Page 2 of 2]

Privacy Act Statement
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection
with your submission of the attached form related to a patent application or patent. Accordingly,
pursuant to the requirements of the Act, please be advised that: (1) the general authority for the
collection of this information is 35 U.S.C. 2(b)(2); (2) furnishing of the information solicited is voluntary;
and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark
Office is to process and/or examine your submission related to a patent application or patent. If you do
not furnish the requested information, the U.S. Patent and Trademark Office may not be able to
process and/or examine your submission, which may result in termination of proceedings or
abandonment of the application or expiration of the patent.
The information provided by you in this form will be subject to the following routine uses:
1. The information on this form will be treated confidentially to the extent allowed under the
Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from
this system of records may be disclosed to the Department of Justice to determine whether
disclosure of these records is required by the Freedom of Information Act.
2. A record from this system of records may be disclosed, as a routine use, in the course of
presenting evidence to a court, magistrate, or administrative tribunal, including disclosures to
opposing counsel in the course of settlement negotiations.
3. A record in this system of records may be disclosed, as a routine use, to a Member of
Congress submitting a request involving an individual, to whom the record pertains, when the
individual has requested assistance from the Member with respect to the subject matter of the
record.
4. A record in this system of records may be disclosed, as a routine use, to a contractor of the
Agency having need for the information in order to perform a contract. Recipients of
information shall be required to comply with the requirements of the Privacy Act of 1974, as
amended, pursuant to 5 U.S.C. 552a(m).
5. A record related to an International Application filed under the Patent Cooperation Treaty in
this system of records may be disclosed, as a routine use, to the International Bureau of the
World Intellectual Property Organization, pursuant to the Patent Cooperation Treaty.
6. A record in this system of records may be disclosed, as a routine use, to another federal
agency for purposes of National Security review (35 U.S.C. 181) and for review pursuant to
the Atomic Energy Act (42 U.S.C. 218(c)).
7. A record from this system of records may be disclosed, as a routine use, to the Administrator,
General Services, or his/her designee, during an inspection of records conducted by GSA as
part of that agency’s responsibility to recommend improvements in records management
practices and programs, under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall
be made in accordance with the GSA regulations governing inspection of records for this
purpose, and any other relevant (i.e., GSA or Commerce) directive. Such disclosure shall not
be used to make determinations about individuals.
8. A record from this system of records may be disclosed, as a routine use, to the public after
either publication of the application pursuant to 35 U.S.C. 122(b) or issuance of a patent
pursuant to 35 U.S.C. 151. Further, a record may be disclosed, subject to the limitations of 37
CFR 1.14, as a routine use, to the public if the record was filed in an application which
became abandoned or in which the proceedings were terminated and which application is
referenced by either a published application, an application open to public inspection or an
issued patent.
9. A record from this system of records may be disclosed, as a routine use, to a Federal, State,
or local law enforcement agency, if the USPTO becomes aware of a violation or potential
violation of law or regulation.