Information Disclosure Statement By Applicant Page 3
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4Application Number
Filing Date
INFORMATION DISCLOSURE
First Named Inventor
STATEMENT BY APPLICANT
Art Unit
( Not for submission under 37 CFR 1.99)
Examiner Name
Attorney Docket Number
CERTIFICATION STATEMENT
Please see 37 CFR 1.97 and 1.98 to make the appropriate selection(s):
That each item of information contained in the information disclosure statement was first cited in any communication
from a foreign patent office in a counterpart foreign application not more than three months prior to the filing of the
information disclosure statement. See 37 CFR 1.97(e)(1).
OR
That no item of information contained in the information disclosure statement was cited in a communication from a
foreign patent office in a counterpart foreign application, and, to the knowledge of the person signing the certification
after making reasonable inquiry, no item of information contained in the information disclosure statement was known to
any individual designated in 37 CFR 1.56(c) more than three months prior to the filing of the information disclosure
statement. See 37 CFR 1.97(e)(2).
See attached certification statement.
The fee set forth in 37 CFR 1.17 (p) has been submitted herewith.
A certification statement is not submitted herewith.
SIGNATURE
A signature of the applicant or representative is required in accordance with CFR 1.33, 10.18. Please see CFR 1.4(d) for the
form of the signature.
Signature
Date (YYYY-MM-DD)
Name/Print
Registration Number
This collection of information is required by 37 CFR 1.97 and 1.98. 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
1.14. This collection is estimated to take 1 hour 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.
EFS Web 2.1.17
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