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U.S. Patent and Trademark Office; U. S. DEPARTMENT OF COMMERCE
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“FEE ADDRESS” INDICATION FORM
Mail Stop M Correspondence
Commissioner for Patents
P.O. Box 1450
Alexandria, VA 22313-1450
- OR -
INSTRUCTIONS: The issue fee must have been paid for application(s) listed on this form. In addition,
only an address represented by a Customer Number can be established as the fee address for maintenance
fee purposes (hereafter, fee address). A fee address should be established when correspondence related to
maintenance fees should be mailed to a different address than the correspondence address for the application.
When to check the first box below: If you have a Customer Number to represent the fee address. When
to check the second box below: If you have no Customer Number representing the desired fee address,
in which case a completed Request for Customer Number (PTO/SB/125) must be attached to this form. For
more information on Customer Numbers, see the Manual of Patent Examining Procedure (MPEP) § 403.
For the following listed application(s), please recognize as the “Fee Address” under the provisions of 37 CFR
1.363 the address associated with:
The attached Request for Customer Number (PTO/SB/125) form.
Completed by (check one):
Attorney or Agent of record ________________
Typed or printed name
Assignee of record of the entire interest. See 37 CFR 3.71.
Statement under 37 CFR 3.73(b) is enclosed.
Requester’s telephone number
Assignee recorded at Reel ________ Frame________
NOTE: Signatures of all the inventors or assignees of record of the entire interest or their representative(s) are required. Submit multiple forms if more that one
signature is required, see below*.
* Total of ____________________________forms are submitted.
This collection of information is required by 37 CFR 1.363. The information is required to obtain or retain a benefit by the public which is to file (and by the USPTO
to process) an appl ication. Confidentiality is governed by 35 U.S.C. 122 and 37 CFR 1. 11 and 1.14. This colle ction is estima ted to take 5 m inutes 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 O ffice, U.S. Depar tment o f Commerc e, P.O . Box 1450, Alex andria, VA 22313- 1450. DO NOT SEND COMPLETE D FORMS TO THIS A DDRESS.
SEND TO: Mail Stop M Correspondence, 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.
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
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
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.
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