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PTO/SB/109 (05-16)
Approved for use through XX/XX/XXXX. OMB 0651-0032
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 contains a valid OMB control number.

DECLARACIÓN PARA SOLICITUD DE PATENTE DE
UTILIDAD O DE DISEÑO (37 CFR 1.63)
DECLARATION FOR UTILITY OR DESIGN PATENT
APPLICATION (37 CFR 1.63)

D

Declaración
presentada junto
a la solicitud
Declaration
Submitted
With Initial
Filing

O
OR

Declaración
presentada después
de la solicitud (se
exige un recargo (37
CFR 1.16(f))
Declaration
Submitted After Initial
Filing (surcharge
(37 CFR 1.16(f))
required)

D

Número de expediente de
abogado
Attorney Docket Number
Primer inventor nombrado
First Named Inventor
RELLENE SI CONOCE LA INFORMACIÓN
COMPLETE IF KNOWN
Solicitud Núm.
Application Number
Fecha de presentación
Filing Date
Unidad de ART
Art Unit

Nombre de examinador
Examiner Name

Declaro que: (1) El domicilio, la dirección postal y la ciudadanía de cada inventor son los que se exponen más adelante junto a su nombre; y (2) considero
que el(los) inventor(es) mencionado(s) más adelante es (son) el inventor original y primero de la materia que se reivindica y para la cual se solicita la
patente de la invención titulada:

I hereby declare that: (1) Each inventor's residence, mailing address, and citizenship are as stated below next to their name; and (2) I believe the
inventor(s) named below to be the original and first inventor(s) of the subject matter which is claimed and for which a patent is sought on the invention
titled:

(Título de la invención)
(Title of the Invention)
cuya solicitud presenté o cuya solicitud autoricé que fuera presentada por otra persona, y
the application of which was made or was authorized to be made by me and
acompaña a este formulario
D se
is attached hereto
O
OR
se presentó el (DÍA/MES/AÑO)

D

como la Solicitud de los Estados Unidos o solicitud internacional PCT número
(si aplica).

y se enmendó el (DÍA/MES/AÑO)
was filed on (MM/DD/YYYY)

as United States Application Number or PCT International Application Number

and was amended on (MM/DD/YYYY)

(if applicable).

Por el presente documento declaro que he revisado la solicitud antes descrita y comprendo el contenido de dicha solicitud, incluso las reivindicaciones,
según enmendada por cualquier enmienda que se haya mencionado anteriormente de manera expresa.
I hereby state that I have reviewed and understand the contents of the above identified application, including the claims, as amended by any amendment
specifically referred to above.
Reconozco el deber de divulgar toda aquella información que sea relevante para la determinación de patentabilidad según se define en 37 CFR 1.56,
incluso para las solicitudes de continuación en parte, información relevante que haya surgido entre la fecha de presentación de la solicitud anterior y la
fecha de presentación nacional o internacional PCT de la solicitud de continuación en parte.
I acknowledge the duty to disclose information which is 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.

[Página 1 de 4]
[Page 1 of 4]
This collection of information is required by 35 U.S.C. 115 and 37 CFR 1.63. 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 21 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:
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/109 (05-16)
Approved for use through XX/XX/XXXX. OMB 0651-0032
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 contains a valid OMB control number.

DECLARACIÓN — Solicitud de patente de utilidad o de diseño
DECLARATION — Utility or Design Patent Application
Reivindicación de beneficios de prioridad extranjera
Claim of Foreign Priority Benefits
Reivindico beneficios de prioridad extranjera de conformidad con 35 U.S.C. 119(a)-(d) o (f ), o 365(b) de cualquier solicitud(es) extranjera(s) que solicite
certificados de derechos de patente, inventor u obtentor vegetal, o 365(a) de cualquier solicitud internacional PCT que haya designado por lo menos un
país que no sea los Estados Unidos de América, que se enumera a continuación y que también se ha identificado a continuación, al marcar la casilla,
cualquier solicitud extranjera que solicite certificado(s) de derechos de patente, inventor u obtentor vegetal, o cualquier solicitud internacional PCT cuya
fecha de presentación sea anterior a la de la solicitud sobre la cual se reivindique prioridad.
I hereby claim foreign priority benefits under 35 U.S.C. 119(a)-(d) or (f ), or 365(b) of any foreign application(s) for patent, inventor's or plant breeder's
rights certificate(s), or 365(a) of any PCT international application which designated at least one country other than the United States of America, listed
below and have also identified below, by checking the box, any foreign application for patent, inventor's or plant breeder's rights certificate(s), or any PCT
international application having a filing date before that of the application on which priority is claimed.
Número(s) de solicitud extranjera
anterior
Prior Foreign Application
Number(s)

País
Country

Fecha de presentación
extranjera
(DÍA/MES/AÑO)
Foreign Filing Date
(MM/DD/YYYY)

No se reclama prioridad
Priority Not Claimed

D
D
D
D
D

¿Se aneja copia certificada?
Certified Copy Attached?

SI
YES

NO
NO

D
D
D
D

D
D
D
D

Números de solicitudes extranjeras adicionales se enumeran en la hoja de datos de prioridad complementaria PTO/SB/02B
que se aneja a este documento.
Additional foreign application number(s) are listed on a supplemental priority data sheet PTO/SB/02B attached hereto.
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[Page 2 of 4]

PTO/SB/109 (05-16)
Approved for use through XX/XX/XXXX. OMB 0651-0032
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 contains a valid OMB control number.

DECLARACIÓN — Solicitud de patente de utilidad o de diseño
DECLARATION — Utility or Design Patent Application
Dirija toda la
correspondencia a:
Direct all
Correspondence to:

D

La dirección asociada
con Cliente Número:
The address
Associated with
Customer Number:

O
OR

D

Dirección postal que se
indica más adelante
Correspondence
address below

Nombre
Name
Dirección
Address
Ciudad
City
País
Country

Estado
State
Teléfono
Telephone

Código postal
Zip
Correo electrónico
Email

ADVERTENCIA:
WARNING:
Se advierte al peticionario/solicitante que evite presentar información personal en los documentos presentados en una solicitud de patente que pueda
contribuir al robo de identidad. La USPTO nunca exige información personal tal como números de seguro social, cuentas bancarias o tarjetas de crédito
(que no sean cheques o el formulario PTO-2038 de autorización de tarjetas de crédito presentado para fines de pago) en apoyo de una petición o
solicitud. Si este tipo de información está incluida en los documentos presentados a la USPTO, los peticionarios/solicitantes deberían considerar quitar
dicha información personal de los documentos antes de presentarlos a la USPTO. Se le informa al peticionario/solicitante que el expediente de una
solicitud de patente está disponible al público después de la publicación de la solicitud (a menos que en la solicitud se pida que no sea publicada de
conformidad con 37 CFR 1.213(a)) o el otorgamiento de una patente. Además, el expediente de una solicitud abandonada también puede estar
disponible al público si se hace referencia a ella en una solicitud publicada o una patente otorgada (véase 37 CFR 1.14). Los cheques y los formularios
PTO-2038 de autorización de tarjetas de crédito presentados para fines de pago no se guardan en el expediente de la solicitud y, por lo tanto, no están
disponibles para el público.
Declaro que todas las declaraciones hechas en este documento son de mi propio conocimiento y son ciertas, y entiendo que todas las declaraciones
hechas a mi leal saber y entender son ciertas; y más aún, que estas declaraciones se han hecho con el conocimiento de que las declaraciones falsas
intencionales y otras de naturaleza similar son punibles por multa o encarcelamiento, o ambos, de conformidad con 18 U.S.C 1001, y que tales
declaraciones falsas intencionales podrían poner en riesgo la validez de la solicitud o de cualquier patente que se haya otorgado al respecto.
Reconozco que cualquier declaración falsa intencional hecha en esta declaración es punible, de conformidad con 18 U.S.C 1001, por multa o
encarcelamiento por un término no mayor de cinco (5) años, o ambas penas.
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.
I hereby declare that all statements made herein of my own knowledge are true and that all statements made 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 so made are punishable by fine or
imprisonment, or both, under 18 U.S.C. 1001 and that such willful false statements may jeopardize the validity of the application or any patent issued
thereon.
I hereby acknowledge that any willful false statement made in this declaration is punishable under 18 U.S.C. 1001 by fine or imprisonment of not more
than five (5) years, or both.
[Página 3 de 4]
[Page 3 of 4]

PTO/SB/109 (05-16)
Approved for use through XX/XX/XXXX. OMB 0651-0032
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 contains a valid OMB control number.

DECLARACIÓN — Solicitud de patente de utilidad o de diseño
DECLARATION — Utility or Design Patent Application

NOMBRE DEL INVENTOR O DEL PRIMER INVENTOR:
NAME OF SOLE OR FIRST INVENTOR:
Nombre (primer nombre y segundo nombre [si alguno])
Given Name (first and middle [if any])

Se ha presentado una solicitud para este inventor sin firma
A petition has been filed for this unsigned inventor
Apellido(s)
Family Name or Surname

Firma del inventor
Inventor’s Signature
Domicilio: Ciudad
Residence: City

Fecha
Date
Estado
State

País
Country

Ciudadanía
Citizenship

Estado
State

Código postal
Zip

País
Country

Dirección postal
Mailing Address
Ciudad
City

D

Inventores adicionales o el representante legal se designan en la
aneja a este documento.
Additional inventors or a legal representative are being named on the

[Página 4 de 4]
[Page 4 of 4]

hoja(s) complementaria(s) PTO/SB/02A o 02LR que se
supplemental sheet(s) PTO/SB/02A or 02LR attached hereto

OMB Clearance and PRA Burden Statement for PTO/SB/109
This collection of information is required by 37 CFR 1.137. 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, 1.14 and 41.6. This form is estimated to
take 21 minutes to complete, including gathering, preparing, and submitting the completed 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 Administration 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: Mail Stop Petition, Commissioner for Patents, P.O. Box 1450, Alexandria, VA
22313-1450.

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 research purposes; to National Archives and
Records Administration for inspection of records; and to 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