Patent Electronic System Verification Form (and Subscriber Agreement)

INSTRUCTIONS FOR COMPLETING THE USPTO
CERTIFICATE ACTION FORM
The completed form should be sent back in the attached envelope or to:
Mail Stop EBC
Commissioner for Patents
P.O. Box 1450
Alexandria, VA 22313-1450
Block 1 -Requestor Status
Independent Inventors should enter a check mark or an “X” in the “Pro Se Inventor” box and
enter a USPTO generated customer number** in the customer number section.
Limited Recognition Practitioners should enter a check mark or an “X” in the “Limited
Recognition Practitioner” box and enter their registration number in the box provided.
Registered Patent Attorneys and Patent Agents should enter a check mark or an “X” in the
“Registered Attorney” box and enter their registration number in the box provided.
Enter additional customer numbers on a separate sheet of paper.
**To obtain a USPTO generated customer number, please fill out the Customer Number form
found at http://www.uspto.gov/web/forms/sb0125.pdf .
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Block 2 -Name and Address
Given Name - The first/given name of an individual. (suggested 50 characters maximum)
Middle Name – The middle name or initial of an individual as understood in the United States.
(suggested 50 characters maximum)
Family Name – The last/family name of an individual. (suggested 50 characters maximum)
Street Address – The street name, number, and any additional components (directional symbols,
etc.) necessary to identify a specific address. (suggested 100 characters maximum)
City – The name of a city associated with the address. (suggested 40 characters maximum)
State Code – The abbreviation for each state of the United States.
Postal Code – In the United States this equates to zip code. (suggested 20 characters maximum).
Country Name – The complete English language name of a nation.

Telephone Number – Please include the country code if outside the United States and area code
for domestic US and Canada. (suggested 40 characters maximum)
Email Address – An individual’s address for electronic communications (e.g., your Internet
address). (maximum 129 characters)
Block 3 – Action
The requester should select a type of request (certificate application, certificate recovery,
certificate association, certificate revocation or name change) by checking the appropriate
box.
Certificate Application -In checking this box you are requesting a digital certificate be issued
for your use in doing business with the United States Patent and Trademark Office (USPTO).
The certificate enables the USPTO to identify your electronic communications and to provide
encrypted communication. This selection is appropriate if you have never held a USPTO issued
digital certificate.
Key Recovery -In checking this box you are requesting that the USPTO (1) revoke your current
certificate and (2) issue you a new certificate with new signature and encryption keys. The
process will provide access to any materials encrypted with the encryption key of the revoked
certificate.
Typically, key recovery is requested due to forgetting the local password that controls the use of
your digital certificate. This local password is chosen by you as part of the enrollment process
and never leaves your computer, so the USPTO has no record of it. Key recovery may also be
needed if through some computer malfunction your software no longer functions. This may be
due to the corruption of the encrypted keys and certificates stored on your computer. If key
recovery is being requested for some other reason, please indicate what happened for example
“suspected key compromise, software inoperable, loss of computer, etc.”
Certificate Association – Associate the current PKI certificate with the customer numbers
detailed in Block 1.
Certificate Revocation -In checking this box you are requesting that the USPTO revoke your
digital certificate. This will make it unusable for new communication with the USPTO.
Typical reasons for requesting revocation are:
(1) A new certificate has been issued to you
(2) You no longer wish to have a certificate
(3) You have changed your legal name
(4) You have lost control of your certificate such that someone else may use it. This is
called key compromise and we request the last date on which you alone controlled the
use of the certificate. If you desire a replacement certificate please complete the Key
Recovery request section.

Block 4 -Requester signature and date.
Block 5 – Identification of Digital Certificate Requestor
All requestors must have their signature notarized by a valid (non-expired) notary. You need to
present to the notary two forms of acceptable identification and have your signature notarized.
IDENTITY PROOFS:
To be sure of the identity of the person requesting the USPTO Certificate the Notary or USPTO
Official completing the USPTO Certificate Action Form must see two (2) forms of identification
at least one of which is a picture ID. Acceptable forms of ID are:
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U.S. Passport
Naturalization Certificate
Certificate of Citizenship
Current, valid driver's license or state identification issued in lieu of a driver’s license
Government ID: city, state or federal
Military Id: military and dependents
Work ID: must be currently employed by the company
Health Insurance card
Marriage or divorce record
Military record
Student ID: must be currently enrolled
Credit Card or Bank Card
Merchant Marines card: also known as a "Seamen's" or "Z" card

SOCIAL SECURITY CARDS ARE NOT ACCEPTABLE AS IDENTIFICATION.
If none of these are available or no acceptable picture ID is available, you will need:
A person who can vouch for the certificate applicant. This person must have known the applicant
for at least 2 years, and have valid proofs of identity as listed above.
AND
The certificate applicant must have two forms of signature ID from the list above. A current
document that has enough information to identify you (e.g., signature, name, address, age, etc.) is
generally acceptable. We cannot accept a birth certificate, Social Security Card or Card Stub.