PTO/SB/43 Disclaimer in Patent Under 37 CFR 1.321(a)

Doc Code:

PTO/SB/43 (07-09)
Approved for use through 07/31/2012. OMB 0651-0031
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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DISCLAIMER IN PATENT UNDER 37 CFR 1.321(a)
Name of Patentee

Docket Number (Optional)

Patent Number

Date Patent Issued

Title of Invention

I hereby disclaim the following complete claims in the above identified patent:

The extent of my interest in said patent is (if assignee of record, state liber and page, or reel and frame, where
assignment is recorded):
The fee for this disclaimer is set forth in 37 CFR 1.20(d).
Patentee claims small entity status. See 37 CFR 1.27.
Small entity status has already been established in this case, and is still proper.
A check in the amount of the fee is enclosed.
Payment by credit card. Form PTO-2038 is attached.
The Director is hereby authorized to charge any fees which may be required or credit any
overpayment to Deposit Account No. ________________ .
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.

Signed at

,

State of

,

this

day of

20

Signature

Registration Number, if
applicable

Typed or printed name of patentee/ attorney or agent of record

Telephone Number

.

Address
City, State, Zip Code or Foreign Country as applicable

This collection of information is required by 37 CFR 1.321. 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 12 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 Information
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: 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. Accordingly,
pursuant to the requirements of the Act, please be advised that: (1) the general authority for the
collection of this information is 35 U.S.C. 2(b)(2); (2) furnishing of the information solicited is voluntary;
and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark
Office is to process and/or examine your submission related to a patent application or patent. If you do
not furnish the requested information, the U.S. Patent and Trademark Office may not be able to
process and/or examine your submission, which may result in termination of proceedings or
abandonment of the application or expiration of the patent.
The information provided by you in this form will be subject to the following routine uses:
1.

2.
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The information on this form will be treated confidentially to the extent allowed under the
Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from
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A record from this system of records may be disclosed, as a routine use, to the public after
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pursuant to 35 U.S.C. 151. Further, a record may be disclosed, subject to the limitations of 37
CFR 1.14, as a routine use, to the public if the record was filed in an application which
became abandoned or in which the proceedings were terminated and which application is
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