PTO/SB/04 Supplemental Declaration for Utility or Design Patent Ap

Doc Code:

PTO/SB/04 (02-07)
Approved for use through XX/XX/XXXX. 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.

Attorney Docket Number

SUPPLEMENTAL
DECLARATION FOR UTILITY
OR DESIGN
PATENT APPLICATION
(37 CFR 1.67)

First Named Inventor
COMPLETE IF KNOWN
Application Number
Filing Date
Art Unit
Examiner Name

I hereby declare that:
Each inventor’s residence, mailing address, and citizenship are as stated below next to their name.
I believe the inventor(s) named below to be the original and first inventor(s) of the subject matter which is claimed and for which a patent is
sought on the invention entitled:

(Title of the invention)
the specification of which
is attached hereto

OR
was filed on (MM/DD/YYYY)

Application Number

as United States Application Number or PCT International

and was amended on (MM/DD/YYYY)

I hereby declare that the subject matter of the
attached amendment
amendment filed on
the invention and was invented before the filing date of the original application, above identified for such invention.

was part of

I hereby state that I have reviewed and understand the contents of the above-identified specification, including the claims, as amended by any
amendment specifically referred to above.
I acknowledge the duty to disclose information which is material to patentability as defined in 37 CFR 1.56, including for continuation-in-part
applications, material information which became available between the filing date of the prior application and the national or PCT international
filing date of the continuation-in-part application.
I hereby claim foreign priority benefits under 35 U.S.C. 119(a)-(d) or (f), or 365(b) of any foreign application(s) for patent, inventor's or plant
breeder's rights certificate(s), or 365(a) of any PCT international application which designated at least one country other than the United
States of America, listed below and have also identified below, by checking the box, any foreign application for patent, inventor's or plant
breeder's rights certificate(s), or of any PCT international application having a filing date before that of the application on which priority is
claimed.
Prior Foreign Application
Country
Foreign Filing Date
Priority
Certified Copy Attached?
Number(s)
(MM/DD/YYYY)
Not Claimed
YES
NO

Additional foreign application numbers are listed on a supplemental priority data sheet PTO/SB/02B attached hereto.

[Page 1 of 2]
This collection of information is required by 35 U.S.C. 115 and 37 CFR 1.63. 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 21
minutes 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
Administrative 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/04 (02-07)

Doc Code:

Approved for use through XX/XX/XXXX. 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.

SUPPLEMENTAL DECLARATION — UTILITY OR DESIGN PATENT APPLICATION
Direct all correspondence to:
OR
Name

The address associated with Customer Number:

Correspondence address below

Address
Address
City

State

Country

ZIP

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 PTO2038 submitted for payment purposes are not retained in the application file and therefore are not publicly available.
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 18 U.S.C. 1001 and that such willful false statements
may jeopardize the validity of the application or any patent issued thereon.
Name of Sole or First Inventor:

A petition has been filed for this unsigned inventor

Given Name

Family Name or Surname

Inventor’s Signature
Residence: City

Date
State

Country

Citizenship

Mailing Address
Mailing Address
City

State

ZIP

Country

Additional inventor(s) or legal representative(s) are being named on the _____ supplemental sheet(s) PTO/SB/ 02A or 02LR attached
hereto.
[Page 2 of 2]

OMB Clearance and PRA Burden Statement for PTO/SB/04
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
take 21 minutes to complete, including gathering, preparing, and submitting the completed 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 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
of records indicates a violation or potential violation of law; to a Federal, state, local, or international agency, in response to its request; to an agency,
organization, or individual for the purpose of performing audit or oversight operations as authorized by law; to non-federal personnel under contract
to the agency; to a court for adjudication and litigation; to the Department of Justice for Freedom of Information Act (FOIA) assistance; to members of
congress working on behalf of an individual; to the Office of Personnel Management (OPM) for personnel research purposes; to National Archives and
Records Administration for inspection of records; and to the Office of Management and Budget (OMB)for legislative coordination and clearance.
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