DOE F 2050.11 Invention Certification for Federal Award

DOE F 2050.11
(08/2021)
All other versions are obsolete

U.S. DEPARTMENT OF ENERGY
INVENTION CERTIFICATION
FOR FEDERAL AWARD

OMB Control No. 1910-0800
Exp. Date:

CLEAR FORM

Prime Contractor Name:
Prime Contract Number:
☐ Not Applicable

Task Order Number:
Certifying Entity Type:

☐ Certification by Prime Contractor
☐ Certification by Subcontractor
Subcontractor Name:
Subcontractor Number

Certification Type:
(Choose only one)

☐ INTERIM Certification – Future Certification Required
The following period is covered by the certification:
TO
Contractor hereby certifies that all subject inventions have been identified and disclosed as required by the
patent clause of the applicable subcontract or contract.
☐ FINAL Certification
This certification is the final and complete patent certification submitted by the undersigned and covers all
subject inventions developed or first reduced to practice in the performance of the above identified task order,
subcontract or contract, except for any subcontracts listed below as not being included in this certification.
Contractor hereby certifies that all subject inventions have been identified and disclosed as required by the
patent clause of the applicable subcontract or contract.
Subcontractor(s):
(Choose only one)

☐ No Subcontractor(s) used to perform experimental, developmental or research work.
☐ Subcontractor(s) used to perform experimental, developmental or research work.
Research and Development Subcontractor:
Subcontractor Name:
Subcontract Number:
Invention Certification:

☐ Included in this certification
☐ Not included in this certification, but provided separately

Research and Development Subcontractor:
Subcontractor Name:
Subcontract Number:
Invention Certification:

☐ Included in this certification
☐ Not included in this certification, but provided separately

DOE F 2050.11
(08/2021)

Section 508 Compliant

DOE F 2050.11
(08/2021)
All other versions are obsolete

OMB Control No. 1910-0800
Exp. Date:

Research and Development Subcontractor:
Subcontractor Name:
Subcontract Number:
Invention Certification:

☐ Included in this certification
☐ Not included in this certification, but provided separately

Research and Development Subcontractor:
Subcontractor Name:
Subcontract Number:
Invention Certification:

☐ Included in this certification
☐ Not included in this certification, but provided separately

Listing of Subject Invention(s):
(Choose only one)

☐ No Subject Invention(s)
☐ Attached: A complete listing of inventions are attached including title, listing of inventors, date reported to
DOE Patent Counsel, and the DOE S-number or iEdison Invention Report Number/EIR Number.
☐ Listed Below
Subject Invention:
DOE S-Number or iEdison Invention Report Number/EIR Number:
Corresponding Patent/Application Number(s):
Inventor(s):
Title:
Subject Invention:
DOE S-Number or iEdison Invention Report Number/EIR Number:
Corresponding Patent/Application Number(s):
Inventor(s):
Title:
Subject Invention:
DOE S-Number or iEdison Invention Report Number/EIR Number:
Corresponding Patent/Application Number(s):
Inventor(s):
Title:

DOE F 2050.11
(08/2021)

Page 2 of 3

Section 508 Compliant

DOE F 2050.11
(08/2021)
All other versions are obsolete

OMB Control No. 1910-0800
Exp. Date:

Subject Invention:
DOE S-Number or iEdison Invention Report Number/EIR Number:
Corresponding Patent/Application Number(s):
Inventor(s):
Title:
Subject Invention:
DOE S-Number or iEdison Invention Report Number/EIR Number:
Corresponding Patent/Application Number(s):
Inventor(s):
Title:
Signature: By signing below, the undersigned is certifying that the above information is accurate and
acknowledges that any inaccurate information provided herein or any failure to timely disclose a subject invention
could result in the loss of rights in or to the subject invention, including losing title to or a license to use the
subject invention. Furthermore, if this certification includes a subcontractor, the undersigned further certifies that
each subcontractor included in this certification has provided written permission to the undersigned to be included
in the certification and that the subcontractor was made aware that any failure to timely disclose a subject
invention could result in the subcontractor losing rights in or to the subject invention, including losing title to or
a license to use the subject invention. The undersigned hereby acknowledges that any willful false statement
made herein is punishable under 18 U.S.C. 1001 by fine or imprisonment of not more than five (5) years, or both.
Full Name:
Title:
Company/Organization Name:
Phone:

Email:

Signature:

Date:

OMB Disclosure Statement
This form is mandatory. Public reporting burden for this collection of information is estimated to average 2 hours
per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23,
Paperwork Reduction Project OMB control number 1910-0800, U.S. Department of Energy, 1000 Independence
Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork
Reduction Project OMB control number 1910-0800, Washington, DC 20503.

DOE F 2050.11
(08/2021)

Page 3 of 3

Section 508 Compliant