PTO/SB/01A Declaration (37 CFR 1.63) For Utility or Design Applicat

PTO/SB/01A (09-12)
Approved for use through XX/XX/XXXX. OMB 0651-0032
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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DECLARATION (37 CFR 1.63) FOR UTILITY OR DESIGN APPLICATION USING AN
APPLICATION DATA SHEET (37 CFR 1.76)
Title of
Invention

As the below named inventor(s), I/we declare that:
This declaration
is directed to:

The attached application, or
United States application or PCT international application number ____________________
filed on ________________________________
As amended on __________________________________________ (if applicable);

I/we believe that I/we am/are the original and first inventor(s) of the subject matter which is claimed and for which a patent is
sought;
I/we have reviewed and understand the contents of the above-identified application, including the claims, as amended by any
amendment specifically referred to above;
I/we acknowledge the duty to disclose to the United States Patent and Trademark Office all information known to me/us to be
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. The above-identified application was made or authorized to be made by me/usL

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.
All statements made herein of my/our own knowledge are true, all statements made herein 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
are punishable by fine or imprisonment, or both, under 18 U.S.C. 1001, and may jeopardize the validity of the application or any
patent issuing thereon. I hereby acknowledge that any willful false statement made in this declaration is punishable under 18
lLSLrL 1001 by fine or imprisonment of not more than five (!) or bothL
FULL NAME OF INVENTOR(S)
Inventor one: _____________________________________________________Date: _______________________________
Signature: _______________________________________________________Citizen of: ____________________________
Inventor two: _____________________________________________________Date: _______________________________
Signature: _______________________________________________________Citizen of: ____________________________
Additional inventors or a legal representative are being named on _______________________additional form(s) attached hereto.
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
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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.

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.