Form Pto/sb/16 - Provisional Application For Patent Cover Sheet

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PTO/SB/16 (01-18)

Approved for use through 11/30/2020. 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 displays a valid OMB control number

PROVISIONAL APPLICATION FOR PATENT COVER SHEET – Page 1 of 2

This is a request for filing a PROVISIONAL APPLICATION FOR PATENT under 37 CFR 1.53(c).

Express Mail Label No. ______________________________________________________________

INVENTOR(S)

Residence

Given Name (first and middle [if any])

Family Name or Surname

(City and either State or Foreign Country)

Additional inventors are being named on the __________________ separately numbered sheets attached hereto.

TITLE OF THE INVENTION (500 characters max):

Direct all correspondence to:

CORRESPONDENCE ADDRESS

The address corresponding to Customer Number:

Firm or

Individual Name

Address

City

State

Zip

Country

Telephone

ENCLOSED APPLICATION PARTS (check all that apply)

Application Data Sheet. See 37 CFR 1.76.

CD(s), Number of CDs _________________________________

Drawing(s)

Number of Sheets __________________

Other (specify) _______________________________________

Number of Pages __________________

Specification (e.g., description of the invention)

Fees Due:

Filing Fee of $280 ($140 for small entity) ($70 for micro entity). If the specification and drawings exceed 100 sheets of paper,

an application size fee is also due, which is $400 ($200 for small entity) ($100 for micro entity) for each additional 50 sheets or fraction

thereof. See 35 U.S.C. 41(a)(1)(G) and 37 CFR 1.16(s).

METHOD OF PAYMENT OF THE FILING FEE AND APPLICATION SIZE FEE FOR THIS PROVISIONAL APPLICATION FOR PATENT

Applicant asserts small entity status. See 37 CFR 1.27.

Applicant certifies micro entity status. See 37 CFR 1.29.

Applicant must attach form PTO/SB/15A or B or equivalent.

A check or money order made payable to the Director of the United States Patent

and Trademark Office is enclosed to cover the filing fee and application size fee (if applicable).

TOTAL FEE AMOUNT ($)

Payment by credit card.

Form PTO-2038 is attached.

The Director is hereby authorized to charge the filing fee and application size fee (if applicable) or credit any overpayment to Deposit

Account Number: __________________.

USE ONLY FOR FILING A PROVISIONAL APPLICATION FOR PATENT

This collection of information is required by 37 CFR 1.51. 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 10 hours 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.