Form Pto/aia/07 - Substitute Statement In Lieu Of An Oath Or Declaration For Reissue Patent Application (35 U.s.c. 115(D) And 37 Cfr 1.64) Page 3

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PTO/AIA/07 (0-1)
Approved for use through 01/31/2020. OMB 0651-0033
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.
SUBSTITUTE STATEMENT IN LIEU OF AN OATH OR DECLARATION FOR
REISSUE PATENT APPLICATION (35 U.S.C. 115(d) AND 37 CFR 1.64)
5HVLGHQFHRIWKHVLJQHU XQOHVVSURYLGHGLQDQDSSOLFDWLRQGDWDVKHHW3726%RUHTXLYDOHQW 
State
County
City
Mailing Address of the signer (unless provided in an application data sheet, PTO/SB/14 or equivalent)
City
Zip
Country
State
Note: Use an additional PTO/AIA/07 form for each inventor who is deceased, legally incapacitated, cannot be found or
reached after diligent effort, or has refused to execute the oath or declaration under 37 CFR 1.63.
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