Form Pto/aia/05 - Reissue Application Declaration By The Inventor Page 2
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3PTO/$,$ (0-)
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.
Docket Number (Optional)
(REISSUE APPLICATION DECLARATION BY THE INVENTOR, page 2)
Note: To appoint a power of attorney, use form PTO/AIA/81.
Correspondence Address: Direct all communications about the application to:
The address associated with Customer Number:
OR
Firm or
Individual Name
Address
City
State
Zip
Country
Telephone
Email
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.
/HJDO name of sole or first inventor ((J*LYHQ1DPH ILUVWDQGPLGGOH LIDQ\ DQG)DPLO\1DPHRU6XUQDPH)
Date 2SWLRQDO
Inventor's 6ignature
Residence &LW\6WDWH&RXQWU\
Mailing Address
&LW\6WDWH=LS&RXQWU\
Additional joint inventors are named on WKHBBBBBBVXSSOHPHQWDO sheet s PTO/$,$/DWWDFKHGKHUHWR.
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