37 Cfr 1.63 - United States Patent And Trademark Office

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PTO/SB/01A (09-12)

Approved for use through 01/31/2014. OMB 0651-0032

U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE

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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

The attached application, or

is directed to:

United States application or PCT international application number ____________________

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. The above-identified application was made or authorized to be made by me/usL

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

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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

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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/our 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. I hereby acknowledge that any willful false statement made in this declaration is punishable under 18

lLSLrL 1001 by fine or imprisonment of not more than five (!) or bothL

FULL NAME OF INVENTOR(S)

Inventor one: _____________________________________________________Date: _______________________________

Signature: _______________________________________________________Citizen of: ____________________________

Inventor two: _____________________________________________________Date: _______________________________

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

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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

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

THIS ADDRESS.

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