USPTO/553 PTAB Applicant Intake Form

USPTO/553 (PTAB Applicant Intake Form)

OMB Control No.: 0651-0082
Expiration Date: XX/XX/XXXX

(https://ptabbar.org/)

Inventor Application for Pro Bono Assistance - PTAB Bar Association

* - indicates required fields
Submission Type

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Personal Information
Salutation *

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First Name *

Middle Name *

Last Name *

Phone *

Email *

Address *

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Address 2

City *

State *

Zip *

Demographic Data
Gender *

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Ethnicity *

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Race *

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Veteran Status *

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Financial Information
Do you have a household income of less than 300% (3x) federal poverty guidelines? *

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(https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines) (https://aspe.hhs.gov/topics/poverty-economicmobility/poverty-guidelines)

* The PTAB Bar Association administrator may ask you to provide proof of income such as 1040 Forms
submitted and accepted by the IRS, Social Security payments, disability payments, disability benefits, Medicaid
information, etc.

Patent Pro Bono Program
Has this application for appeal assistance been prosecuted by a volunteer associated with the
USPTO's patent pro bono program? *

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If yes, please provide *

Name of Regional Program

Patent Attorney/Agent Name

Patent Attorney/Agent Registration Number

* The PTAB Bar Association may reach out to 1) the prior regional program to confirm your financial status for
participation and 2) your prior attorney for information on why he/she considers the application ripe for appeal.

Knowledge
You must demonstrate knowledge of the ex parte appeal process by sucessfully completeting a video training
course. The video training course involves two videos. The first video explains how the PTAB Pro Bono Program
works and the second video walks through the ex parte appeal process. You must complete both videos.

Have you completed the training course offered by the USPTO
(https://www.uspto.gov/patents/patent-trial-and-appeal-board/patent-trial-and-appeal-boardpro-bono-program-independent)? *

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Are you currently represented by an attorney? *

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Invention / Appeal Information
Title of Invention *

Basic Subject Area *

Bio/Lifesciences
Ornamental Design
Mechanical
Checmical
Electical/Computer
select all that apply

Application No. *

Certification of Micro Entity Status
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Is there a Certification of Micro Entity Status in your application? *

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Status of Application *

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Date of Last Office Action *

Briefly describe the basis for appeal (please limit explanation to what you believe to be the error in
the broadest independent claim rejected by the Examiner) *

Disclosures
By submitting my electronic signature below, and by submitting this application, I am making the following
representations:

1. The information provided by me in this application is, to the best of my knowledge, compete and
accurate.
2. I understand that submitting false or misleading information may result in delay or denial of services.
3. I understand that misrepresenting the financial information used to establish my qualification for microentity status to the United States Patent and Trademark Office may constitute fraud, and could result in
the invalidation of the patent or application.
4. I will notify the PTAB Bar Association program if any of the information in this application materially
changes prior to placement with an attorney, especially if any inventor's income should suddenly
increase.
5. I have not shared any confidential information in filling out this application with the PTAB Bar Association.
6. I understand that continuation in the program is at the discretion of the program administrator, and that
filling out this application does not entitle me to any services.
7. I agree and understand that this application does not create an attorney-client relationship between any
named inventor or myself and any individual attorney or the PTAB Bar Association.
8. I understand that the matter may be placed with either a patent attorney or patent agent, and that this
person's representation may be limited to the filing of a pre-appeal and Notice of Appeal for the invention
referenced in this application.
9. I understand that PTAB Bar Association’s scope of services are limited to the placement of cases for filing
patent appeals and that if I have another legal issue prior to placement with a patent attorney/agent,
PTAB Bar Association will not handle the placement of these issues. I further understand that while my
assigned attorney may take on these additional matters, they may charge additional fees for these
services.
10. I understand that the applicant remains responsible for the payment of all necessary governmental fees
and ancillary fees when necessary.

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Electronic Signature and Date Stamp
Please sign below using your mouse or your finger on a touchscreen device

Clear

Signature Date *

After submitting this application, the program administrator will review the details and will attempt to contact
you within a reasonable period of time. Please only call the office or e-mail for confirmation if you do not
receive an automated confirmation e-mail. Keep in mind that the office is usually closed on and around major
holidays, and delays are likely during these periods of the year.

Please review your application carefully before submitting. Submitting your application multiple times will cause
unnecessary delays. We ask you to please be certain of your responses before pressing the submit button. If
you need to make material changes after hitting submit, please e-mail us at [email protected]
(mailto:[email protected]), but DO NOT submit and then go back to make changes and submit again.

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A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor
shall a person be subject to a penalty for failure to comply with an information collection subject to
the requirements of the Paperwork Reduction Act of 1995, unless the information collection has a
valid OMB Control Number. The OMB Control Number for this information collection is 0651-0082.
Public burden for this form is estimated to average 10 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the information collection. Send comments regarding this
burden estimate or any other aspect of this information collection, including suggestions for
reducing this burden to the Office of the Chief Administrative Officer, United States Patent and
Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email
[email protected].

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