PTO/SB/16 Provisional Application for Patent Cover Sheet

PTO/SB/16 (12-22)
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

PROVISIONAL APPLICATION FOR PATENT COVER SHEET – Page 1 of 2

This is a request for filing a PROVISIONAL APPLICATION FOR PATENT under 37 CFR 1.53(c).
Priority Mail Express® Label No. ______________________________________________________________

INVENTOR(S)
Given Name (first and middle [if any])

Family Name or Surname

Residence
(City and either State or Foreign Country)

Additional inventors are being named on the __________________ separately numbered sheets attached hereto.

TITLE OF THE INVENTION (500 characters max):

CORRESPONDENCE ADDRESS

Direct all correspondence to:
The address corresponding to Customer Number:
OR

Firm or
Individual Name
Address
City

State

Zip

Country

Telephone

Email

ENCLOSED APPLICATION PARTS (check all that apply)

Application Data Sheet. See 37 CFR 1.76.

CD(s), Number of CDs _________________________________

Drawing(s)

Other (specify) _______________________________________

Number of Sheets __________________

Specification (e.g., description of the invention)

Number of Pages __________________

Fees Due: Filing Fee of $300 ($120 for small entity) ($60 for micro entity). If the specification and drawings exceed 100 sheets of paper,
an application size fee is also due, which is $420 ($168 for small entity) ($84 for micro entity) for each additional 50 sheets or fraction
thereof. See 35 U.S.C. 41(a)(1)(G) and 37 CFR 1.16(s).
METHOD OF PAYMENT OF THE FILING FEE AND APPLICATION SIZE FEE FOR THIS PROVISIONAL APPLICATION FOR PATENT
Applicant asserts small entity status. See 37 CFR 1.27.
Applicant certifies micro entity status. See 37 CFR 1.29.
Applicant must attach form PTO/SB/15A or B or equivalent.

A check or money order made payable to the Director of the United States Patent
and Trademark Office is enclosed to cover the filing fee and application size fee (if applicable).

TOTAL FEE AMOUNT ($)

Payment by credit card. Form PTO-2038 is attached.
The Director is hereby authorized to charge the filing fee and application size fee (if applicable) or credit any overpayment to Deposit
Account Number: __________________.

USE ONLY FOR FILING A PROVISIONAL APPLICATION FOR PATENT

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 0651-0032. Public burden for this form is estimated to average 10 hours 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. If filing this completed form by mail, 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/16 (12-22)
Approved for use through 05/31/2024. 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

PROVISIONAL APPLICATION FOR PATENT COVER SHEET – Page 2 of 2
The invention was made by an agency of the United States Government or under a contract with an agency of the United States
Government. (NOTE: Providing this information on a provisional cover sheet, such as this Provisional Application for Patent Cover Sheet
(Form PTO/SB/16), does not satisfy the requirement of 35 U.S.C. 202(c)(6), which requires that the specification contain a statement
specifying that the invention was made with Government support and that the Government has certain rights in the invention.)
No.
Yes, the invention was made by an agency of the U.S. Government. The U.S. Government agency name is:
_____________________________________________________________________________________________________________
Yes, the invention was made under a contract with an agency of the U.S. Government.
The contract number is: _________________________________________________________________________________________
The U.S. Government agency name is: _____________________________________________________________________________
_____________________________________________________________________________________________________________
In accordance with 35 U.S.C. 202(c)(6) and 37 CFR 401.14(f)(4), the specifications of any United States patent applications and any
patent issuing thereon covering the invention, including the enclosed provisional application, must state the following:
‘‘This invention was made with government support under [IDENTIFY THE CONTRACT] awarded by [IDENTIFY THE FEDERAL
AGENCY]. The government has certain rights in the invention.”

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.
SIGNATURE __________________________________________________________ DATE _________________________
TYPED OR PRINTED NAME ______________________________________________ REGISTRATION NO. ______________
(if appropriate)
TELEPHONE __________________________________________ DOCKET NUMBER _______________________________

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.