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`USin.F‘atem and Tradamafk Office;MUS:l‘JEPfiRTMENT OF COMMERCE
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`: As the below named inveuier. E hereby daclare that:
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`This declaralimz E]
`is directfld to;
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`he anarchist: applacatmn, or
`[:3 United States appllcatlzm or PST intamazienai appiisallon numbar'
`filed an
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`____________________________
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`The above-identified application was made- or authcsrlzeci to the. made by me.
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`3
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`.l belies-v9 that i am the original inventor m an original joint invantor of as claimed invention in the apglicalion.
`
`i‘herehy acknowledge that any willful false statement made in this deciamtiun is mmishabie under '18 {1.3.6. 1am
`by fine or lmpfisonment of not more than five (5) years), at bath.
`
`WRRMNG:
`
`Petitiflnariappficant is cautioned t0 await} submitting persanal lnfeflnaéian in éacu‘mems mm in a patent appliaatim-that may
`. contribute to identity theft. Perscnal. information such as social security flumihers, bank account numbers, 0r credit care! numbers
`1 {ether than a check or credit card authcrizafion form 9TQ~2Q38 aubmi‘tt‘ed far payment purposes} is: never requlmé by ma USPTO
`i to wpmm a million 9:" an applicaiimn.
`if this type: of pea-91ml lnfarmaiian is included in flocumem‘s submit-lad m the: USPTQ,
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`petitianers/applicams should cansldar mamzilng such personal infarmatimn fmm the documents before submitting imam to the
`USPTG. Petitionerlappllwnt is advised that the; record ofa pa‘tant applicatlon is available-to the public. after publication ofthe
`application (unlegs a nowpublication requssl in campii'anca with 3? CFR ‘§.218{a) is made in the application} 0r issuance m“ a
`pageant. Furthermam. the record from an abandnnetfi applicatlan may also be available to {he public: if the application is
`{slammedm a main,“shed applifiation Dr an issued patent (sea 37’ {ZIP-R ’l M} Checks and credit card authorization forms
`. 5-"($2338 submitted far payment purpmaa are met retalnad in the application:file and therefme are mitt publicly available.
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`LEGAL NAME (3F lNVENTQR
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`Signature:
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` Note: An applicalicn data sham {PTOISEINm equivalerfi), including naméng the entire lnventiva entity, must acmmpa‘ny this farm or must have
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`5 bean pra'viousily mad. Use an additional P'R‘fiAle farm for each addiiional invmtur.
`This collamion a? lnfarrmsllxnn‘ls malted by 35 U:3G 115 and 32’ CFR 1 as me lnfomaklm ls raqulrad m entrain m rataln 3 banal}? by 8?“? Wm1‘- Wl‘ifih “1 30 file laud
`by {he USMC) m {31'00653} an apgllwtlmw. mnfifidentiallty‘l8 gavgmed by 35 U.8C122 and32%”:FR ‘3. "H and 1 M This calla-:tlon is. estimated to teke‘! minute to
`mmpiata. Excluding gathering, pmparmg. and 5&1meth the sampleth appilnatiufi farm to. the US$331). Time will vary depending 95mm the individual 3333. Any
`commenfis an we amount :1? firms yea manly-e to cnmnlm‘e this; farm andfor suggastions for maiuulng this burden, slmzld m sent {a the Chief lnfomation Gfilcm. {3.53.
`Patent and Tradamark filfim. U3. Daparlmeni offlummerce, RC). Bax ”MSG, Nsxandria. VA 223.1234 $5.0. no NUT SEND FEE-3 OR COMPLETE} FORMS TB
`Wis ADGHEES‘ $53M? Tits: Gammlsaiamr far Patents, #3:}. flux 14%, Mexandria, VA malarial).
`if you "sad assismnma En nnmfidefing this farm, call i-Séa-W'O-Siw ezz‘d rifled upllca a,
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`
`
`Privacy Act Statement
`
`The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection
`with your submission of the attached form related to a patent application or patent. Accordingly,
`pursuant to the requirements of the Act, please be advised that: (1) the general authority for the
`collection of this information is 35 U.S.C. 2(b)(2); (2) furnishing of the information soiicited is voluntary;
`and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark
`Office is to process andfor examine your submission related to a patent application or patent. if you do
`not furnish the requested information, the U.S. Patent and Trademark Office may not be able to
`process andlor examine your submission, which may resuit in termination of proceedings or
`abandonment of the application or expiration of the patent.
`
`The information provided by you in this form will be subject to the following routine uses:
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`1. The information on this form will be treated confidentially to the extent allowed under the
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`A record from this system of records may be disclosed, as a routine use, to the pubiic after
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