PTO/SB/91 Deposit Account Order Form

Doc Code:

PTO/SB/91 (07-09)
Approved for use through XX/XX/XXXX. OMB 0651-0031
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.
(Also PTO Form 3.76)
DATE

DEPOSIT ACCOUNT ORDER FORM

This form is to be used only for orders, the costs of which are to be charged against United States Patent and
Trademark Office (USPTO) Deposit Accounts. IT MUST NOT BE USED FOR orders when payment is made by
cash, checks, credit cards, or coupons. In addition, it should not be used for ordering printed copies of U.S.
Patents. Use a separate form for each of the following types of service ordered: Recordings, Reproductions, Title
Reports, Translations. Mail to: Director of the USPTO, P.O. Box 1450, Alexandria, VA 22313-1450.
NAME AND ADDRESS FOR DEPOSITOR

ACCOUNT NUMBER

FOR OFFICE USE ONLY

YOUR ORDER NUMBER

DESCRIPTION OF ARTICLES FOR SERVICE TO BE FURNISHED

If additional space is needed attach separate sheet.

WARNING: Information on this form may become public. Credit card information should not
be included on this form. Provide credit card information and authorization on PTO-2038.
_____________________________________________________________________________
Signature

_________________________
Date

_____________________________________________________________________________
Typed or Printed Name

__________________________
Registration Number, if applicable

For prompt, accurate shipment please complete the following mailing label - please print or type.
U.S. DEPARTMENT OF COMMERCE
U.S. Patent and Trademark Office
P.O. Box 1450
Alexandria, VA 22313-1450
OFFICIAL BUSINESS

_______________________________________
(Name)

Return after five days

_______________________________________
(Street Address)
_____________________________________________

(City, State, Zip Code)

YOUR ORDER NUMBER
This collection of information is required by 37 CFR 1.25. 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 15 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: Director of the USPTO, 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 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
purposes; to National Archives and Records Administration for inspection of records; and to
research
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