PTO/SB/83 Request for Withdrawal as Attorney or Agent and Change o

Doc Code: PET.POA.WDRW
Document Description: Petition to withdraw attorney or agent (SB83)
PTO/SB/83 (04-13)
Approved for use through XX/XX/XXXX. OMB Control Number 0651-0035
U.S. Patent and Trademark Office, 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.

Application Number

REQUEST FOR WITHDRAWAL
AS ATTORNEY OR AGENT AND
CHANGE OF
CORRESPONDENCE ADDRESS
To:

Filing Date
First Named Inventor
Art Unit
Examiner Name
Practitioner Docket
Number

Commissioner for Patents
P.O. Box 1450
Alexandria, VA 22313-1450

Please withdraw me as attorney or agent for the above-identified patent application, and
all the practitioners of record;
the practitioners (with registration numbers) of record listed on the attached paper(s); or
the practitioners of record associated with Customer Number: _______________________________
NOTE: The immediately preceding box should only be marked when the practitioners were appointed using the listed
Customer Number.
The reason(s) for this request are those described in 37 CFR:
11.116(a)(1)

11.116(a)(2)

11.116(a)(3)

11.116(b)(1)

11.116(b)(2)

11.116(b)(3)

11.116(b)(4)

11.116(b)(5)

11.116(b)(6)

11. 116(b)(7) Please explain below:

Certifications
Check each box below that is factually correct. WARNING: If a box is left unchecked, the request will likely not be
approved.
1.
I/We have given reasonable notice to the client, prior to the expiration of the response period, that the
practitioner(s)
intend to withdraw from employment.
2.

I/We have delivered to the client or a duly authorized representative of the client all papers and property (including
funds) to which the client is entitled.

3.

I/We have notified the client of any responses that may be due and the time frame within which the client must
respond.

Please provide an explanation, if necessary:

[Page 1 of 2]
This collection of information is required by 37 CFR 1.36. 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 information collection is estimated to take 30 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 Office of the Chief
Administrative Officer, U.S. Patent and Trademark Office, 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/83 (04-13)
Approved for use through XX/XX/XXXX. OMB Control Number 0651-0035
U.S. Patent and Trademark Office, 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.

REQUEST FOR WITHDRAWAL AS ATTORNEY OR AGENT
AND CHANGE OF CORRESPONDENCE ADDRESS
Complete the following section only when the correspondence address will change. Changes of address will only be accepted to the first
named inventor or an assignee that has properly made itself of record pursuant to 37 CFR 3.71.
Change the correspondence address and direct all future correspondence to:
A.

The address of the first named inventor or assignee associated with Customer Number: ____________________________

OR
B.

First Named
Inventor or Assignee

Address

City

State

Telephone

Zip

Country

Email

I am authorized to sign on behalf of myself and all withdrawing practitioners.

Signature

Name

Registration No.

Address

City

Date

State

Zip

Country

Telephone No.

NOTE: Withdrawal is effective when approved rather than when received.
[Page 2 of 2]
This collection of information is required by 37 CFR 1.36. 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 information collection is estimated to take 30 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 Office of the Chief
Administrative Officer, U.S. Patent and Trademark Office, 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.

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 37 CFR 1.36. This information is covered by a System of
Records Notice which identifies the categories of individuals covered by the system including inventors, legal
representatives for inventors, and other persons authorized by law to make applications for patent. The information in
this system of records is used to manage all records of applicants and legal representatives including name,
citizenship, residence, post office address and other information pertaining to activities in connection with the invention
for which a patent is sought.
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 assistance; to members of
congress working on behalf of an individual; to the Office of Personnel Management for personnel research purposes;
to National Archives and Records Administration for records management activities; and to the Office of Management
and Budget 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