Form PTO-1595 Patent Recordation Form Cover Sheet

Form PTO-1595 (Rev. 06-12)
OMB No. 0651-0027 (exp. 04/30/2015)

Doc Code:

U.S. DEPARTMENT OF COMMERCE
United States Patent and Trademark Office

RECORDATION FORM COVER SHEET

PATENTS ONLY

To the Director of the U.S. Patent and Trademark Office: Please record the attached documents or the new address(es) below.

1. Name of conveying party(ies)

2. Name and address of receiving party(ies)
Name: ____________________________________
Internal Address:____________________________

Additional name(s) of conveying party(ies) attached?

Yes

No

___________________________________________________

Street Address: _____________________________
3. Nature of conveyance/Execution Date(s):
Execution Date(s)_____________________________
___________________________________________________

Assignment

Merger

Security Agreement

Change of Name

Joint Research Agreement

City:______________________________________
State: _____________________________________

Government Interest Assignment

Country:___________________Zip:______________

Executive Order 9424, Confirmatory License

Other__________________________________
4. Application or patent number(s):
A. Patent Application No.(s)

Additional name(s) & address(es) attached?

Yes

No

This document serves as an Oath/Declaration (37 CFR 1.63).
B. Patent No.(s)

Additional numbers attached?

5. Name and address to whom correspondence
concerning document should be mailed:
Name:_____________________________________

Yes

No

6. Total number of applications and patents
involved:____________________________

7. Total fee (37 CFR 1.21(h) & 3.41) $____________

Internal Address:_____________________________
___________________________________________
Street Address:_______________________________
___________________________________________
City: _______________________________________

Authorized to be charged to deposit account
Enclosed
None required (government interest not affecting title)
8. Payment Information

State:_____________________Zip:_______________
Phone Number: _______________________________
Docket Number:_____________________________
Email Address:_ ______________________________

Deposit Account Number __________________
Authorized User Name ____________________

9. Signature:
Signature
Name of Person Signing

Date
Total number of pages including cover
sheet, attachments, and documents:

Documents to be recorded (including cover sheet) should be faxed to (571) 273-0140, or mailed to:
Mail Stop Assignment Recordation Services, Director of the USPTO, P.O.Box 1450, Alexandria, V.A. 22313-1450

Guidelines for Completing Patents Cover Sheets
(PTO-1595)
Cover Sheet information must be submitted with each document to be recorded. If the document to be
recorded concerns both patents and trademarks separate patent and trademark cover sheets, including any attached
pages for continuing information, must accompany the document. All pages of the cover sheet should be numbered
consecutively, for example, if both a patent and trademark cover sheet is used, and information is continued on one
additional page for both patents and trademarks, the pages of the cover sheet would be numbered from 1
to 4.
Item 1. Name of Conveying Party(ies).
Enter the full name of the party(ies) conveying the interest. If there is insufficient space, enter a check mark
in the "Yes" box to indicate that additional information is attached. The name of the additional conveying party(ies)
should be placed on an attached page clearly identified as a continuation of the information Item 1. Enter a check mark
in the "No" box, if no information is contained on an attached page. If the document to be recorded is a joint research
agreement, enter the name(s) of the party(ies) other than the owner of the patent or patent application as the conveying
party(ies).
Item 2. Name and Address of Receiving Party(ies).
Enter the name and full address of the first party receiving the interest. If there is more than one party
receiving the interest, enter a check mark in the "Yes" box to indicate that additional information is attached. Enter a
check mark in the "No" box, if no information is contained on an attached page. If the document to be recorded is a
joint research agreement, enter the name(s) of the patent or patent application owner(s) as the receiving party.
Item 3. Nature of Conveyance/Execution Date(s).
Enter the execution date(s) of the document. It is preferable to use the name of the month, or an abbreviation
of that name, in order that confusion over dates is minimized. Place a check mark in the appropriate box describing the
nature of the conveying document. If the "Other" box is checked, specify the nature of the conveyance.
Item 4. Application Number(s) or Patent Number(s).
Indicate the application number(s), and/or patent number(s) against which the document is to be recorded.
National application numbers must include both the series code and a six-digit number (e.g., 07/123,456), and
international application numbers must be complete (e.g., PCT/US91/12345).
Enter a check mark in the appropriate box: "Yes" or "No " if additional numbers appear on attached pages.
Be sure to identify numbers included on attached pages as the continuation of Item 4. Also enter a check mark if this
Assignment is being filed as an Oath/Declaration ( 37 CFR 1.63).
Item 5. Name and Address of Party to whom correspondence concerning the document should be
mailed. Enter the name and full address of the party to whom correspondence is to be mailed.
Item 6. Total Applications and Patents involved.
Enter the total number of applications and patents identified for recordation. Be sure to include all
applications and patents identified on the cover sheet and on additional pages.
Block 7. Total Fee Enclosed.
Enter the total fee enclosed or authorized to be charged. A fee is required for each application and patent
against which the document is recorded.
Item 8. Payment Information.
Enter the deposit account number and authorized user name to authorize charges.
Item 9. Signature.
Enter the name of the person submitting the document. The submitter must sign and date the cover sheet.
Enter the total number of pages including the cover sheet, attachments, and document.
This collection of information is required by 35 USC 261 and 262 and 15 USC 1057 and 1060. The information is used by the public to submit (and by
the USPTO to process) patent and trademark assignment requests. After the USPTO records the information, the records for patent and trademarks,
assignments, and other associated documents can be inspected by the public. To view documents recorded under secrecy orders or documents recorded
due to the interest of the federal government, a written authorization must be submitted. This collection is estimated to take 30 minutes to complete,
including gathering, preparing, and submitting the form to the USPTO. 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 Manager of the Assignment Division, USPTO, P.O. Box 1450, Alexandria, VA 22313-1450.
DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS. SEND TO: Mail Stop Assignment Recordation Services, Director of the
USPTO, P.O. Box 1450, Alexandria, VA 22313-1450.

Privacy Act Statement for Patent Assignment Recordation Form Cover Sheet
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in
connection with the above request for information. This collection of information is authorized
by 35 U.S.C. 1, 2, 261 and E.O. 9424. This information will primarily be used by the USPTO
for the recordation of assignments related to patents and patent applications. Submission of this
information is voluntary but is required in order for the USPTO to record the requested
assignment. If you do not provide the information required on the cover sheet, the assignment
will not be recorded, and all documents will be returned to you.

After the information is recorded, the records and associated documents can be inspected by the
public and are not confidential, except for documents that are sealed under secrecy orders or
related to unpublished patent applications. Assignment records relating to unpublished patent
applications are maintained in confidence in accordance with 35 U.S.C. 122. Records open to
the public are searched by users for the purpose of determining ownership for other property
rights with respect to patents and trademarks.
Routine uses of the information you provide may also include disclosure to appropriate Federal,
state, local, or foreign agencies in support of their enforcement duties and statutory or regulatory
missions, including investigating potential violations of law or contract and awarding contracts
or other benefits; to a court, magistrate, or administrative tribunal in the course of presenting
evidence; to members of Congress responding to requests for assistance from their constituents;
to the Office of Management and Budget in connection with the review of private relief
legislation; to the Department of Justice in connection with a Freedom of Information Act
request; to a contractor in the performance of their duties; to the Office of Personnel
Management for personnel studies; and to the General Services Administration (GSA) as part of
their records management responsibilities under the authority of 44 U.S.C. 2904 and 2906. Such
disclosure to GSA shall not be used to make determinations about individuals.