PTO/SB/52 Reissue Application Declaration by the Assignee

PTO/SB/52 (09-12)
Approved for use through 08/31/2013. OMB 0651-0033
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.

Docket Number (optional)

REISSUE APPLICATION DECLARATION BY THE ASSIGNEE
I hereby declare that:
The residence, mailing address and citizenship of the inventors are stated below.
I am authorized to act on behalf of the following assignee:
and the title of my position with said assignee is:
The entire title to the patent identified below is vested in said assignee.
Inventor

Citizenship

Residence/Mailing Address
Inventor

Citizenship

Residence/Mailing Address
Additional Inventors are named on separately numbered sheets attached hereto.
Patent Number
Date of Patent Issued

I believe said inventor(s) to be the original and first inventor(s) of the subject matter which is described and claimed in said
patent, for which a reissue patent is sought on the invention entitled:

the specification of which
is attached hereto.
was filed on

as reissue application number

/

and was amended on
(If applicable)
I have reviewed and understand the contents of the above identified specification, including the claims, as amended by any
amendment referred to above. This application was made or was authorized to be made by me.
I acknowledge the duty to disclose information which is material to patentability as defined in 37 CFR 1.56.
I hereby claim foreign priority benefits under 35 U.S.C. 119(a)-(d) or (f), or 365(b). Attached is form PTO/SB/02B
(or equivalent) listing the foreign applications.
I verily believe the original patent to be wholly or partly inoperative or invalid, for the reasons described
below. (Check all boxes that apply.)
by reason of a defective specification or drawing.
by reason of the patentee claiming more or less than he had the right to claim in the patent.
by reason of other errors.
[Page 1 of 2]
This collection of information is required by 37 CFR 1.175. 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 30 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/52 (09-12)
Approved for use through 08/31/2013. OMB 0651-0033
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.

REISSUE APPLICATION DECLARATION BY THE ASSIGNEE

Docket Number (Optional)

At least one error upon which reissue is based is described as follows:

[Attach additional sheets, if needed.]
All errors corrected in this reissue application arose without any deceptive intention on the part of the applicant.
I hereby appoint:
Practitioners associated with Customer Number:
OR
Practitioner(s) named below:
Name
Registration Number

as my/our attorney(s) or agent(s) to prosecute the application identified above, and to transact all business in the United
States Patent and Trademark Office connected therewith.
Correspondence Address: Direct all communications about the application to:
The address associated with Customer Number:
OR
Firm or
Individual
Name

Address
City

State

Zip

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 false
statements may jeopardize the validity of the application, any patent issuing thereon, or any patent to which this
declaration is directed. I hereby acknowledge that any willful false statement made in this declaration is punishable under 18
U.S.C. 1001 by fine or imprisonment of not more than five (5) years, or both.
Signature

Date

Full name of person signing (given name, family name)
Address of Assignee

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Privacy Act Statement

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection
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