Form 35421 Patent Information Submitted With the Filing of an NDA,

Form Approved: OMB No. 0910-0513
Expiration Date: 10/31/2013
See OMB Statement on Page 3.

Department of Health and Human Services
Food and Drug Administration

PATENT INFORMATION SUBMITTED WITH THE FILING
OF AN NDA, AMENDMENT, OR SUPPLEMENT
For Each Patent That Claims a Drug Substance
(Active Ingredient), Drug Product (Formulation and Composition)
and/or Method of Use

NDA NUMBER
NAME OF APPLICANT/NDA HOLDER

The following is provided in accordance with Section 505(b) and (c) of the Federal Food, Drug, and Cosmetic Act.
TRADE NAME (OR PROPOSED TRADE NAME)

ACTIVE INGREDIENT(S)

STRENGTH(S)

DOSAGE FORM

This patent declaration form is required to be submitted to the Food and Drug Administration (FDA) with an NDA application,
amendment, or supplement as required by 21 CFR 314.53 at the address provided in 21 CFR 314.53(d)(4).
Within thirty (30) days after approval of an NDA or supplement, or within thirty (30) days of issuance of a new patent, a new patent
declaration must be submitted pursuant to 21 CFR 314.53(c)(2)(ii) with all of the required information based on the approved NDA or
supplement. The information submitted in the declaration form submitted upon or after approval will be the only information relied
upon by FDA for listing a patent in the Orange Book.
For hand-written or typewriter versions (only) of this report: If additional space is required for any narrative answer (i.e., one that
does not require a "Yes" or "No" response), please attach an additional page referencing the question number.
FDA will not list patent information if you submit an incomplete patent declaration or the patent declaration indicates the
patent is not eligible for listing.
For each patent submitted for the pending NDA, amendment, or supplement referenced above, you must submit all the
information described below. If you are not submitting any patents for this pending NDA, amendment, or supplement,
complete above section and sections 5 and 6.
1. GENERAL
a. United States Patent Number

b. Issue Date of Patent

d. Name of Patent Owner

Address (of Patent Owner)

c. Expiration Date of Patent

City/State

e. Name of agent or representative who resides or maintains
a place of business within the United States authorized to
receive notice of patent certification under section 505(b)(3)
and (j)(2)(B) of the Federal Food, Drug, and Cosmetic Act
and 21 CFR 314.52 and 314.95 (if patent owner or NDA
applicant/holder does not reside or have a place of
business within the United States)

ZIP Code

FAX Number (if available)

Telephone Number

E-Mail Address (if available)

Address (of agent or representative named in 1.e.)

City/State
ZIP Code

FAX Number (if available)

Telephone Number

E-Mail Address (if available)

f. Is the patent referenced above a patent that has been submitted previously for the
approved NDA or supplement referenced above?

Yes

No

g. If the patent referenced above has been submitted previously for listing, is the expiration
date a new expiration date?

Yes

No

FORM FDA 3542a (10/10)

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PSC Graphics (301) 443-1090

EF

For the patent referenced above, provide the following information on the drug substance, drug product and/or method of
use that is the subject of the pending NDA, amendment, or supplement.
2. Drug Substance (Active Ingredient)
2.1 Does the patent claim the drug substance that is the active ingredient in the drug product
described in the pending NDA, amendment, or supplement?

Yes

No

2.2 Does the patent claim a drug substance that is a different polymorph of the active
ingredient described in the pending NDA, amendment, or supplement?

Yes

No

2.3 If the answer to question 2.2 is "Yes," do you certify that, as of the date of this declaration, you have test
data demonstrating that a drug product containing the polymorph will perform the same as the drug product
described in the NDA? The type of test data required is described at 21 CFR 314.53(b).

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

2.4 Specify the polymorphic form(s) claimed by the patent for which you have the test results described in 2.3.

2.5 Does the patent claim only a metabolite of the active ingredient pending in the NDA or supplement?
(Complete the information in section 4 below if the patent claims a pending method of using the pending
drug product to administer the metabolite.)
2.6 Does the patent claim only an intermediate?

2.7 If the patent referenced in 2.1 is a product-by-process patent, is the product claimed in the
patent novel? (An answer is required only if the patent is a product-by-process patent.)

3. Drug Product (Composition/Formulation)
3.1 Does the patent claim the drug product, as defined in 21 CFR 314.3, in the pending NDA, amendment,
or supplement?
3.2 Does the patent claim only an intermediate?

3.3 If the patent referenced in 3.1 is a product-by-process patent, is the product claimed in the
patent novel? (An answer is required only if the patent is a product-by-process patent.)

4. Method of Use
Sponsors must submit the information in section 4 for each method of using the pending drug product for which approval is being
sought that is claimed by the patent. For each pending method of use claimed by the patent, provide the following information:
4.1 Does the patent claim one or more methods of use for which approval is being sought in
the pending NDA, amendment, or supplement?
4.2 Patent Claim Number(s) (as listed in the patent)

4.2a If the answer to 4.2 is
"Yes," identify with specificity the use with reference to the proposed
labeling for the drug
product.

Does (Do) the patent claim(s) referenced in 4.2 claim a
pending method of use for which approval is being sought
in the pending NDA, amendment, or supplement?

Yes

No

Yes

No

Use: (Submit indication or method of use information as identified specifically in the proposed labeling.)

5. No Relevant Patents
For this pending NDA, amendment, or supplement, there are no relevant patents that claim the drug substance (active ingredient),
drug product (formulation or composition) or method(s) of use, for which the applicant is seeking approval and with respect to which
a claim of patent infringement could reasonably be asserted if a person not licensed by the owner of the patent engaged in the
manufacture, use, or sale of the drug product.

FORM FDA 3542a (10/10)

Yes

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6. Declaration Certification
6.1 The undersigned declares that this is an accurate and complete submission of patent information for the NDA,

amendment, or supplement pending under section 505 of the Federal Food, Drug, and Cosmetic Act. This timesensitive patent information is submitted pursuant to 21 CFR 314.53. I attest that I am familiar with 21 CFR 314.53 and
this submission complies with the requirements of the regulation. I verify under penalty of perjury that the foregoing is
true and correct.
Warning: A willfully and knowingly false statement is a criminal offense under 18 U.S.C. 1001.
6.2 Authorized Signature of NDA Applicant/Holder or Patent Owner (Attorney, Agent, Representative or
other Authorized Official) (Provide Information below)

Date Signed

NOTE: Only an NDA applicant/holder may submit this declaration directly to the FDA. A patent owner who is not the NDA applicant/
holder is authorized to sign the declaration but may not submit it directly to FDA. 21 CFR 314.53(c)(4) and (d)(4).
Check applicable box and provide information below.
NDA Applicant/Holder

NDA Applicant’s/Holder’s Attorney, Agent (Representative) or other
Authorized Official

Patent Owner

Patent Owner’s Attorney, Agent (Representative) or Other Authorized
Official

Name

Address

City/State

ZIP Code

Telephone Number

FAX Number (if available)

E-Mail Address (if available)

The public reporting burden for this collection of information has been estimated to average 20 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
1350 Piccard Drive, Room 400
Rockville, MD 20850
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.

FORM FDA 3542a (10/10)

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INFORMATION AND INSTRUCTIONS FOR FORM 3542a
PATENT INFORMATION SUBMITTED WITH THE FILING
OF AN NDA, AMENDMENT OR SUPPLEMENT

.

General Information

.
.

.
.
.
.
.

To submit patent information to the agency the appropriate
patent declaration form must be used. Two forms are available
for patent submissions. The approval status of your New Drug
Application will determine which form you should use.
Form 3542a should be used when submitting patent information
with original NDA submissions, NDA amendments and NDA
supplements prior to approval.
Form 3542 should be used after NDA or supplement approval.
This form is to be submitted within 30 days after approval of an
application. This form should also be used to submit patent
information relating to an approved supplement under 21 CFR
314.53(d) to change the formulation, add a new indication or
other condition of use, change the strength, or to make any other
patented change regarding the drug, drug product, or any
method of use.
Form 3542 is also to be used for patents issued after drug
approval. Patents issued after drug approval are required to be
submitted within 30 days of patent issuance for the patent to be
considered "timely filed."

1e) Answer this question if applicable. If patent owner and NDA
applicant/holder reside in the United States, leave space
blank.

2. Drug Substance (Active Ingredient)
Complete all items in this section if the patent claims the drug
substance that is the subject of the pending NDA, amendment, or
supplement.
2.4) Name the polymorphic form of the drug identified by the
patent.
2.5) A patent for a metabolite of the approved active ingredient
may not be submitted. If the patent claims an approved
method of using the approved drug product to administer the
metabolite, the patent may be submitted as a method of use
patent depending on the responses to section 4 of this form.
2.7) Answer this question only if the patent is a product-byprocess patent.

3. Drug Product (Composition/Formulation)

Only information from form 3542 will be used for Orange Book
publication purposes.

Complete all items in this section if the patent claims the drug
product that is the subject of the pending NDA, amendment, or
supplement.

Forms should be submitted as described in 21 CFR 314.53.
Sending an additional copy of form 3542 to the Orange Book
Staff will expedite patent publication in the Orange Book. The
Orange Book Staff address (as of April 2007) is: Orange Book
Staff, Office of Generic Drugs OGD/HFD-610, 7500 Standish
Place, Rockville, MD 20855.

3.3) An answer to this question is required only if the referenced
patent is a product-by-process patent.

The receipt date is the date that the patent information is date
stamped in the central document room. Patents are considered
listed on the date received.
Additional copies of these forms may be downloaded from the
Internet at: http://www.fda.gov/opacom/morechoices/fdaforms/
fdaforms.html.

First Section
Complete all items in this section.

1. General Section
Complete all items in this section with reference to the patent
itself.
1c) Include patent expiration date, including any Hatch-Waxman
patent extension already
granted. Do not include any
applicable pediatric exclusivity. The agency will include
pediatric exclusivities where applicable upon publication.
1d) Include full address of patent owner. If patent owner resides
outside the U.S. indicate the country in the zip code block.

FORM FDA 3542a (10/10)

4. Method of Use
Complete all items in this section if the patent claims a method of
use of the drug product that is the subject of the pending NDA,
amendment, or supplement (pending method of use).
4.2)

For each pending method of use claimed by the patent,
identify by number the claim(s) in the patent that claim the
pending use of the drug. An applicant may list together
multiple patent claim numbers and information for each
pending method of use, if applicable. However, each
pending method of use must be separately listed within this
section of the form.

4.2a) Specify the part of the proposed drug labeling that is
claimed by the patent.

5. No Relevant Patents
Complete this section only if applicable.

6. Declaration Certification
Complete all items in this section.
6.2) Authorized signature. Check one of the four boxes that best
describes the authorized signature.

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