Form PTO/SB/16 Provisional Application for Patent Cover Sheet

PTO/SB/16 (03‐13) 
Approved for use through 01/31/2014. OMB 0651‐0032 
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 

PROVISIONAL APPLICATION FOR PATENT COVER SHEET – Page 1 of 2 
This is a request for filing a PROVISIONAL APPLICATION FOR PATENT under 37 CFR 1.53(c). 
Express Mail Label No. ______________________________________________________________ 

INVENTOR(S)
Given Name (first and middle [if any]) 

Family Name or Surname 

Residence 
(City and either State or Foreign Country)

Additional inventors are being named on the __________________ separately numbered sheets attached hereto. 

TITLE OF THE INVENTION (500 characters max):

Direct all correspondence to:                                                  CORRESPONDENCE ADDRESS
          The address corresponding to Customer Number: 
OR 
          Firm or 
          Individual Name 
Address 
City 

State

Zip

Country 

Telephone

Email

ENCLOSED APPLICATION PARTS (check all that apply)
          Application Data Sheet. See 37 CFR 1.76. 

         CD(s), Number of CDs __________________ 

          Drawing(s)     Number of Sheets __________________ 

          Other (specify) ________________________________________ 

          Specification (e.g., description of the invention)     Number of Pages __________________ 

Fees Due:  Filing Fee of $260 ($130 for small entity) ($65 for micro entity). If the specification and drawings exceed 100 sheets of paper, an 
application size fee is also due, which is $400 ($200 for small entity) ($100 for micro entity) for each additional 50 sheets or fraction thereof. 
See 35 U.S.C. 41(a)(1)(G) and 37 CFR 1.16(s). 

METHOD OF PAYMENT OF THE FILING FEE AND APPLICATION SIZE FEE FOR THIS PROVISIONAL APPLICATION FOR PATENT
          Applicant asserts small entity status. See 37 CFR 1.27. 
          Applicant certifies micro entity status. See 37 CFR 1.29. 
          Applicant must attach form PTO/SB/15A or B or equivalent. 
          A check or money order made payable to the Director of the United States Patent 
          and Trademark Office is enclosed to cover the filing fee and application size fee (if applicable).                   TOTAL FEE AMOUNT ($) 
          Payment by credit card. Form PTO‐2038 is attached. 
          The Director is hereby authorized to charge the filing fee and application size fee (if applicable) or credit any overpayment to Deposit 
          Account Number: __________________. 

USE ONLY FOR FILING A PROVISIONAL APPLICATION FOR PATENT 
This collection of information is required by 37 CFR 1.51. 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 10 hours 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/16 (03‐13) 
Approved for use through 01/31/2014. OMB 0651‐0032 
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 

PROVISIONAL APPLICATION FOR PATENT COVER SHEET – Page 2 of 2 
The invention was made by an agency of the United States Government or under a contract with an agency of the United States Government.
          No. 
          Yes, the invention was made by an agency of the U.S. Government. The U.S. Government agency name is: __________________________ 
          ________________________________________________________________________________________________________________  
          Yes, the invention was made under a contract with an agency of the U.S. Government. The name of the U.S. Government agency and 
          Government contract number are: ____________________________________________________________________________________ 
          ________________________________________________________________________________________________________________  

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. 
SIGNATURE __________________________________________________________  DATE _________________________ 
TYPED OR PRINTED NAME ______________________________________________   REGISTRATION NO. ______________ 
                                                                                                                                                       (if appropriate) 
TELEPHONE __________________________________________  DOCKET NUMBER _______________________________ 

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 record.
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 issued patent.
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.