Form PTO-1595 Patents Recordation Form Cover Sheet

Form PTO-1595 (Rev. 6-18)
OMB No. 0651-0027 (exp. 06/30/2021)
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.

U.S. DEPARTMENT OF COMMERCE
United States Patent and Trademark Office

RECORDATION FORM COVER SHEET

PATENTS ONLY
To the Director of the U.S. Patent and Trademark Office: Please record the attached documents or the new address(es) below.

1. Name of conveying party(ies)

2. Name and address of receiving party(ies)
Name:
Internal Address:

Additional name(s) of conveying party(ies) attached?

Yes

No

Street Address:

3. Nature of conveyance/Execution Date(s):
Execution Date(s)
Assignment

Merger

Security Agreement

Change of Name

Joint Research Agreement

City:
State:

Government Interest Assignment

Country:

Executive Order 9424, Confirmatory License

Other

Zip:

Additional name(s) & address(es) attached?

4. Application or patent number(s):

Yes

No

This document serves as an Oath/Declaration (37 CFR 1.63).
B. Patent No.(s)

A. Patent Application No.(s)

Additional numbers attached?

5. Name and address to whom correspondence
concerning document should be mailed:
Name:

Yes

No

6. Total number of applications and patents
involved:

7. Total fee (37 CFR 1.21(h) & 3.41)

$

Internal Address:
Authorized to be charged to deposit account
Enclosed

Street Address:

None required (government interest not affecting title)
8. Payment Information

City:

Zip:

State:
Phone Number:

Deposit Account Number

Docket Number:
Authorized User Nam e

Email Address:_
9. Signature:
Signature
Name of Person Signing

Date
Total number of pages including cover
sheet, attachments, and documents:

Documents to be recorded (including cover sheet) should be faxed to (571) 273-0140, or mailed to:
Mail Stop Assignment Recordation Services, Director of the USPTO, P.O.Box 1450, Alexandria, V.A. 22313-1450

Guidelines for Completing Patents Cover Sheets
(PTO-1595)
Cover Sheet information must be submitted with each document to be recorded. If the document to be
recorded concerns both patents and trademarks separate patent and trademark cover sheets, including any attached
pages for continuing information, must accompany the document. All pages of the cover sheet should be numbered
consecutively, for example, if both a patent and trademark cover sheet is used, and information is continued on one
additional page for both patents and trademarks, the pages of the cover sheet would be numbered from 1
to 4.
Item 1. Name of Conveying Party(ies).
Enter the full name of the party(ies) conveying the interest. If there is insufficient space, enter a check mark
in the "Yes" box to indicate that additional information is attached. The name of the additional conveying party(ies)
should be placed on an attached page clearly identified as a continuation of the information Item 1. Enter a check mark
in the "No" box, if no information is contained on an attached page. If the document to be recorded is a joint research
agreement, enter the name(s) of the party(ies) other than the owner of the patent or patent application as the conveying
party(ies).
Item 2. Name and Address of Receiving Party(ies).
Enter the name and full address of the first party receiving the interest. If there is more than one party
receiving the interest, enter a check mark in the "Yes" box to indicate that additional information is attached. Enter a
check mark in the "No" box, if no information is contained on an attached page. If the document to be recorded is a
joint research agreement, enter the name(s) of the patent or patent application owner(s) as the receiving party.
Item 3. Nature of Conveyance/Execution Date(s).
Enter the execution date(s) of the document. It is preferable to use the name of the month, or an abbreviation
of that name, in order that confusion over dates is minimized. Place a check mark in the appropriate box describing the
nature of the conveying document. If the "Other" box is checked, specify the nature of the conveyance.
Item 4. Application Number(s) or Patent Number(s).
Indicate the application number(s), and/or patent number(s) against which the document is to be recorded.
National application numbers must include both the series code and a six-digit number (e.g., 07/123,456), and
international application numbers must be complete (e.g., PCT/US91/12345).
Enter a check mark in the appropriate box: "Yes" or "No " if additional numbers appear on attached pages.
Be sure to identify numbers included on attached pages as the continuation of Item 4. Also enter a check mark if this
Assignment is being filed as an Oath/Declaration ( 37 CFR 1.63).
Item 5. Name and Address of Party to whom correspondence concerning the document should be
mailed. Enter the name and full address of the party to whom correspondence is to be mailed.
Item 6. Total Applications and Patents involved.
Enter the total number of applications and patents identified for recordation. Be sure to include all
applications and patents identified on the cover sheet and on additional pages.
Block 7. Total Fee Enclosed.
Enter the total fee enclosed or authorized to be charged. A fee is required for each application and patent
against which the document is recorded.
Item 8. Payment Information.
Enter the deposit account number and authorized user name to authorize charges.
Item 9. Signature.
Enter the name of the person submitting the document. The submitter must sign and date the cover sheet.
Enter the total number of pages including the cover sheet, attachments, and document.
This collection of information is required by 35 U.S.C. 261 and 262. According to 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. The number assigned to this information collection is
0651-0027. Public burden for this form is estimated to average 30 minutes per response, including the time for reviewing instructions,
completing, and submitting the information collection. Response to this information collection is voluntary, however if you do not provide this
information USPTO may be unable to process your request. 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: Mail Stop Assignment Recordation Branch, Director of the USPTO, P.O. Box 1450, Alexandria, VA 22313-1450.

Privacy Act Statement for Patent Assignment Recordation Form Cover Sheet
The United States Patent and Trademark Office (USPTO) collects this information under authority of 37
CFR 3.11. The information in this system of records is used to manage requests to record patent and
trademark assignment documents. This may involve the collection of serial number, filing date, title of
invention, applicant’s or inventor’s address and addresses of applicant’s duly appointed representatives.
Failure to provide any part of the requested information may result in an inability to process requests to
record patent and trademark assignment documents.
The information you provide 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, whether civil, criminal, or regulatory in nature, 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 share relevant information
contained in this system with the Office of Management and Budget (OMB), which performs legislative
coordination and clearance functions.. The applicable Privacy Act System of Records Notice for this
information is COMMERCE/PAT-TM-9, Patent Assignment Records: Federal Register / Vol. 78, No.
61 / Friday, March 29, 2013 / Notices available at https://www.govinfo.gov/content/pkg/
FR-2013-03-29/pdf/2013-07378.pdf