PTO/AlA/m (06-12)
`Approved for use through 11/30/2020. OMB 0651~0032
`US. Patent and Trademark Office; US. DEPARTMENT OF COMMERCE
`‘ns are required to respond to a oolie
`n of information '
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`‘ ‘ss it disp‘"
`" the Paperwork Reduction Act of 1995, no p * "
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`QECLARATBQN {3? CFR1.53) FQR UTlLlT‘l’ 0R QESEGN APPLBCATEQN USENG AN
`APPLECATlON DATA $HEET {37 GFR 1.73)
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`Tifle of
`invention
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`FRESENTENQ RELATED POENTS QF ENTEREST
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`As the below named inventor, hereby declare that:
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`This declaration
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`is directed to:
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`"""
`[E]
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`m.
`ine attached a
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`trcation, or
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`on
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`United States application or PCT international application number
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`filed on
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`The above-identified application was made or authorized to be made by me.
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`believe that i am the original inventor or an original joint inventor of a claimed invention in the application.
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`l hereby acknowledge that any wiiifui false statement made in this declaration is punishable under 18 U38. 1061
`by fine or imprisonment of not more than five (5) years, or both.
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`WARNENG:
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`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.
`it this type of personal information is included in documents submitted to the USPTO,
`petitionersiepplicants 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 nonubublication request in compliance with 37 CPR 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 it the application is
`referenced in a published application or an issued patent (see 37 CFR 1.14). Checks and credit 0' rd authorization forms
`PTO—2038 submitted for payment purposes are not retained in the application file and therefore are not publicly available.
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`3
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`I
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`LEGAL NAME OF lNVE—ENTOR
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`inventor: BRiANJANDRECH______________________________________________________________________________ Date (Optional) :_____________________________________________________________
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`Signature:
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`”3721
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`Note: An application data sheet (PTO/88144 or equivalent), including naming the entire inventive entity, must accompany this form or must have
`been previously filed. Use an additional P‘TO/AlA/Ot form for each additional inventor.
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`This collection of information is required by 35 USO. 115 and 3.7 CFR 1.63. The int rmation is required to obtain or retain a benefit by the public which is to the (and
`by the USPTO to process) an application. Confidentiality is governed by 35 U.S.C. 122 and 3'7 CFR ‘l
`‘l and 1.14. This collection is estimated to take 1 minute to
`complete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the individual case. Any
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`comments on the amount oltinte you require to complete this form and/or sugw. stions for reducing this burden, should be sent to the Chief information Officer, US.
`Patent and Trademark Office, US. Department of Commerce, PO. Box 1450, Alexandria, VA 22313-1450. DO NOT SEND FEES OR COMPLETED FORM-S TO
`THlS ADDRESS. SEND Ti): Commissioner for Patents. Rf). Box 1451). Alexandria, VA 22313—1453.
`If you need assistance in completing the form, call 1—2300»?!23—9199 and select option 25
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`

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`Privacy Act Statement
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`The Privacy Act of 1974 (Rt... caste) requires that you be given certain information in connection
`with your submission ofthe attached form retated to a patent application or patent. Accordingly,
`pursuant to the requirements otthe Act, please be advised that: (t) the generat authority torthe
`collection otthis information is 35 USS. 2(b)(2); (2) turnishing otthe inl‘ormation solicited is voluntary;
`and (3) the principal purpose for which the information is used by the US. Patent and Trademark
`Office is to process and/or examine your submission related to a patent application or patent. if you do
`not furnish the requested information, the US. Patent and Trademark Office may not be able to
`process and/or examine your submission, which may result in termination of proceedings or
`abandonment of the appiication or expiration otthe 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 coniidentiaity to the extent allowed underthe
`Freedom of information Act (5 USE. 552) and the Privacy Act (5 USE 552a). Records from
`this system ol‘ records may be disctosed to the Department ol‘ Justice to determine whether
`disclosure ot’these records is required by the Freedom of information Act.
`A record from this system of records may be disclosed, as a routine use, in the course of
`presenting evidence to a court, magistrate, or administrative tribunal, including disclosures to
`opposing counset in the course of settlement negotiations.
`A record in this system or" records may be disclosed, as a routine use, to a Member of
`Congress submitting a request involving an individual, to whom the record pertains, when the
`individual has requested assistance from the Member with respect to the sublect matter ofthe
`record.
`
`A record in this system or" records may be disclosed, as a routine use, to a contractor otthe
`Agency having need for the information in orderto perform a contract. Recipients of
`information shalt be required to comply with the requirements ofthe Privacy Act ot1974, as
`amended, pursuant to 5 USE. 552a(m).
`A record retated to an international Apptication filed under the Patent Cooperation Treaty in
`this system of records may be disclosed, as a routine use, to the lnternational l3ureau olthe
`World tntellectual Property Organization, pursuant to the Patent Cooperation Treaty.
`A record in this system of records may be disclosed, as a routine use, to another l‘ederat
`agency for purposes of National Security review (35 USS. t8‘i) and for review pursuant to
`the Atomic Energy Act (42 U.S.C3. 218(c)).
`A record from this system of records may be disclosed, as a routine use, to the Administrator,
`General Services, or his/her designee, during an inspection or records conducted by GSA as
`part of that agency's responsibility to recommend improvements in records management
`practices and programs, under authority of 44 U.S.C. 2904 and 2906. $uch disctosure shall
`be made in accordance with the GSA regutations governing inspection of records torthis
`purpose, and any other relevant (to, GSA or Commerce) directive. Such disctosure shalt not
`be used to make determinations about individuals.
`
`A record from this system of records may be disclosed, as a routine use, to the public alter
`either publication otthe application pursuant to 35 USE. 1220)) or issuance of a patent
`pursuant to 35 USE. 151. Further. a record may be disclosed, subject to the limitations of 37
`CPR 1.14, as a routine use, to the public itthe record was tiled in an application which
`became abandoned or in which the proceedings were terminated and which apptication is
`referenced by either a published application, an application open to public inspection or an
`issued patent.
`A record from this system of records may be disclosed, as a routine use, to a Federal, State,
`or local law enforcement agency, ifthe USPTO becomes aware or a violation or potential
`violation of law or regulation.
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