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PTO/SB/01A (02-07)
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 if displays a valid OMB control number.

DECLARATION (37 CFR 1.63) FOR UTILITY OR DESIGN APPLICATION USING AN
APPLICATION DATA SHEET (37 CFR 1.76)
Title of
Invention

As the below named inventor(s), I/we declare that:
This declaration is directed to:
The attached application, or
Application No. ____________________ filed on ________________________________
As amended on __________________________________________ (if applicable);
I/we believe that I/we am/are the original and first inventor(s) of the subject matter which is claimed and for which a patent is
sought;
I/we have reviewed and understand the contents of the above-identified application, including the claims, as amended by any
amendment specifically referred to above;
I/we acknowledge the duty to disclose to the United States Patent and Trademark Office all information known to me/us to be
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.

WARNING:
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.
All statements made herein of my/own knowledge are true, all statements made herein 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 are
punishable by fine or imprisonment, or both, under 18 U.S.C. 1001, and may jeopardize the validity of the application or any
patent issuing thereon.
FULL NAME OF INVENTOR(S)
Inventor one: _________________________________________________________________________________________
Signature: _______________________________________________________Citizen of: ____________________________
Inventor two: _________________________________________________________________________________________
Signature: _______________________________________________________Citizen of: ____________________________
Additional inventors or a legal representative are being named on _______________________additional form(s) attached hereto.
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 1
minute 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.

OMB Clearance and PRA Burden Statement for PTO/SB/01A
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 1 minute 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