Form PTO/AIA/05 Reissue Application Declaration by the Inventor


'RF&RGH5(,6'(&/
'RFXPHQW'HVFULSWLRQ5HLVVXHOath or 'HFODUDWLRQ

PTO/$,$5 (0-)
Approved for use through XX/XX/XXXX. 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 INVENTOR

I hereby declare that: 
Each inventor’s residenceDQG mailing address are stated below next to their name. 
I believe ,DPWKHRULJLQDOLQYHQWRURUDQRULJLQDOMRLQWLQYHQWRU of the subject matter which is described and claimed
in patent number 
, granted
and for which a
reissue patent is sought on the invention titled _______BB_________________________________________________,
,

the specification of which
is attached hereto.
was filed on

as reissue application number

7KHDERYHLGHQWLILHGDSSOLFDWLRQZDVPDGHRUDXWKRUL]HGWREHPDGHE\PH
I KHUHE\DFNQRZOHGJHWKDWDQ\ZLOOIXOIDOVHVWDWHPHQWPDGHLQWKLVGHFODUDWLRQLVSXQLVKDEOHXQGHU1886&E\ILQH
RULPSULVRQPHQWRIQRWPRUHWKDQILYH\HDUVRUERWK.
I 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.
At least one error upon which reissue is based is described below.If the reissue is a broadening
reissue, DFODLPWKDWWKHDSSOLFDWLRQVHHNVWREURDGHQPXVWEHLGHQWLILHG:

[Page 1 of 2]

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 currently valid OMB Control
Number. The OMB Control Number for this information collection is 0651-0033. Public burden for this form is estimated to average 46 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 Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria,
VA 22313-1450 or email [email protected]. 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/$,$5 (0-)
Approved for use through 03/31/2023. 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 INVENTOR, page 2)

Note: To appoint a power of attorney, use form PTO/AIA/81.
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.




/HJDO name of sole or first inventor ((J*LYHQ1DPHILUVWDQGPLGGOHLIDQ\DQG)DPLO\1DPHRU6XUQDPH)

Inventor's 6ignature

Date2SWLRQDO

Residence&LW\6WDWH&RXQWU\
Mailing Address

&LW\6WDWH=LS&RXQWU\

Additional joint inventors are named on WKHBBBBBBVXSSOHPHQWDO sheets PTO/$,$/DWWDFKHGKHUHWR.

[Page 2 of 2]

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 the information in this record under authority of 35
U.S.C. 2. The USPTO’s system of records is used to manage all applicant and owner information
including name, citizenship, residence, post office address, and other information with respect to
inventors and their legal representatives pertaining to the applicant's/owner’s activities in connection
with the invention for which a patent is sought or has been granted. The applicable Privacy Act
System of Records Notice for the information collected in this form is COMMERCE/PAT-TM-7 Patent
Application Files, available in the Federal Register at 78 FR 19243 (March 29, 2013). https://
www.govinfo.gov/content/pkg/FR-2013-03-29/pdf/2013-07341.pdf
Routine uses of the information in this record may include disclosure to: 1) law enforcement, in the
event that the system of records indicates a violation or potential violation of law; 2) a Federal, state,
local, or international agency, in response to its request; 3) a contractor of the USPTO having need
for the information in order to perform a contract; 4) the Department of Justice for determination of
whether the Freedom of Information Act (FOIA) requires disclosure of the record; 5) a Member of
Congress submitting a request involving an individual to whom the record pertains, when the
individual has requested the Member’s assistance with respect to the subject matter of the record; 6)
a court, magistrate, or administrative tribunal, in the course of presenting evidence, including
disclosures to opposing counsel in the course of settlement negotiations; 7) the Administrator,
General Services Administration (GSA), or their designee, during an inspection of records conducted
by GSA under authority of 44 U.S.C. 2904 and 2906, in accordance with the GSA regulations and any
other relevant (i.e., GSA or Commerce) directive, where such disclosure shall not be used to make
determinations about individuals; 8) 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)); 9) the Office of
Personnel Management (OPM) for personnel research purposes; and 9) the Office of Management
and Budget (OMB) for legislative coordination and clearance.
If you do not furnish the information requested on this form, the USPTO may not be able to process
and/or examine your submission, which may result in termination of proceedings, abandonment of the
application, and/or expiration of the patent.

Additional Uses
Additional USPTO uses of the information in this record may include disclosure to: 1) the International
Bureau of the World Intellectual Property Organization, if the record is related to an international
application filed under the Patent Cooperation Treaty; 2) the public i) after publication of the
application pursuant to 35 U.S.C. 122(b), ii) after issuance of a patent pursuant to 35 U.S.C. 151, iii) 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 inspections, or an issued patent, or iv) without publication of the application or patent under
the specific circumstances provided for by 37 CFR 1.14(a)(1)(v)-(vii); and/or 3) the National Archives
and Records Administration, for inspection of records.