PTO/SB/106 Declaration for Utility or Design Patent Application - J

PTO/SB/106 (5-00)
Approved for use through 10/31/02. 0MB 0651-0032
Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
Under the Paperwork Reduction Act of 1995, no persons arc required to respond to a collection of information unless it displays a valid 0MB control number.

Declaration and Power of Attorney for Patent Application

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Japanese Language Declaration

As a below named inventor. I hereby declare that:

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My residence, post office address and citizenship are as stated
next to my name.

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I believe I am the original, first and sole inventor (if only one name
is listed below) or an original, first and joint inventor (if plural names
are listed below) of the subject matter which is claimed and for which
a patent is sought on the invention entitled

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the specification of which is attached hereto unless the following
box is checked:

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was filed on __________
as United States Application Number or
PCT International Application Number
________ and was amended on
________ (if applicable).

I hereby state that I have reviewed and understand the contents of
the above identified specification, including the claims, as amended
by any amendment referred to above.

I acknowledge the duty to disclose information which is material to
patentability as defined in Title 37, Code of Federal Regulations,
Section 1.56.

Burden Hour Statement: This form is estimated to take 0.4 hours to complete. Time will vary depending upon the need of the individual case. Any
comments on the amount of time you are required to complete this form should be sent to Chief Information Officer, U.S. Patent and Trademark Office,
Washington, DC 20231. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS. SEND TO: Commissioner of Patents and Trademarks,
Washington, DC 20231.
Page I of3

PTO/SB/106 (5-00)
Approved for use through 10/31/02. 0MB 0651-0032
Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
Llmkr the Paperwork Reduction Act of 1995, no persons are required to respond lo a collection of information unless it displays a valid 0MB control number.

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Japanese Language Declaration
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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
Section 1001 of Title 18 of the United States Code and that such
willful false statements may jeopardize the validity of the application
or any patent issued thereon.

OMB Clearance and PRA Burden Statement for PTO/SB/106
This collection of information is required by 37 CFR 1.137. 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, 1.14 and 41.6. This form is estimated to
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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 Administration 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: Mail Stop Petition, Commissioner for Patents, P.O. Box 1450, Alexandria, VA
22313-1450.

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. The United States Patent and Trademark Office (USPTO) collects this information under authority of 5 CFR 339.205.
The information in this system of records is used to manage all records of applicant including name, citizenship, residence, post office address and
other information pertaining to the applicant's activities in connection with the invention for which a patent is sought. Statements containing various
kinds of information with respect to inventors who are deceased or incapacitated, or who are unavailable or unwilling to make application for patent.
The information obtain is protected from disclosure to third parties in accordance with the Privacy Act.
However, routine uses of this information may include disclosure to the following: to law enforcement and investigation in the event that the system
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Failure to provide any part of the requested information may result in an inability to process requests for access and information. The applicable
Privacy Act System of Records Notice for this information is COMMERCE/PAT-TM-7 Patent Application Files, available at Federal Register /Vol. 78, No.
61 / Friday, March 29, 2013 /Notices 19243. https://www.govinfo.gov/content/pkg/FR-2013-03-29/pdf/2013-07341.pdf