Doc Code: TR.PROV
`Document Description: Provisional Cover Sheet (SB16)
`
`PTO/SB/16 (02-18)
`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 respondto a collection of information unless it displays a valid OMB control number
`
`Provisional Application for Patent Cover Sheet
`This is a requestforfiling a PROVISIONAL APPLICATION FOR PATENTunder 37 CFR 1.53(c)
`
`Inventor(s)
`
`Inventor 1
`
`
`Country j
`State
`City
`Family Name
`Middle Name
`Given Name
`
`
`
`
`Add
`All Inventors Must Be Listed — Additional Inventor Information blocks may be
`generated within this form by selecting the Add button.
`
`
`Title of Invention
`
`DEGRADANT COMPOUND IN A MEDICAMENT
`
`Customer Number
`
`Attorney Docket Number (if applicable)
`
`4902.0120001
`
`Correspondence Address
`
`Direct all correspondenceto (select one):
`
`@) The address corresponding to Customer Number
`
`©) Firm orIndividual Name
`
`
`
`The invention was made by an agencyof the United States Governmentor under a contract with an agency of the United
`States Government.
`
`Government agency and Government contract number are:
`
`Yes, the invention was made by an agency of the United States Government. The U.S. Government agency name is:
`Yes, the invention was under a contract with an agency of the United States Government. The nameof the U.S.
`
`EFS - Web 1.0.2
`
`

`

`Doc Code: TR.PROV
`Document Description: Provisional Cover Sheet (SB16)
`
`PTO/SB/16 (02-18)
`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 respondto a collection of information unless it displays a valid OMB control number
`
`Entity Status
`Applicant asserts small entity status under 37 CFR 1.27 or applicant certifies micro entity status under 37 CFR 1.29
`
`@) Applicant asserts small entity status under 37 CFR 1.27
`
`C) Applicant certifies micro entity status under 37 CFR 1.29. Applicant must attach form PTO/SB/15A or B or equivalent.
`
`Warning
`
`Petitioner/applicant is cautioned to avoid submitting personal information in documentsfiled 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 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 CFR1.14}. 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.
`
`
`
`Signature
`
`Please see 37 CFR 1.4(d} for the form of the signature.
`
`Signature Date (YYYY-MM-DD) pozr-t018|10-18Marsha RoseGillentine, Reg. No. 58,403/
`
`
`
`
`First Name fresrarrore|Rose Registration Number feos|(If appropriate}Last Name
`
`
`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 USPTOto 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 8 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 amountof 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 FORMSTO THIS ADDRESS. This
`form can only be used when in conjunction with EFS-Web. If this form is mailed to the USPTO, it may cause delays in handling
`the provisional application.
`
`EFS - Web 1.0.2
`
`

`

`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 paten. 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 solicited is voluntary; and (3) the principal purpose for which the information is used by the U_S_. 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 U.S. Patent and Trademark Office may not be able to process and/or examine your
`submission, which may result in termination of proceedings or abandonmentof the application or expiration of the patent.
`
`The information provided by you in this form will be subject to the following routine uses:
`
`1.
`
`The information on this form will be treated confidentially to the extent allowed under the Freedom of Information
`Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from this system of records may be disclosed to the
`Departmentof Justice to determine whether disclosure of 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 counsel in the course of settlement
`negotiations.
`A record in this system of records may be disclosed, as a routine use, to a Member of Congress submitting a
`requestinvolving an individual, to whom the record pertains, when the individual has requested assistance from the
`Member with respect to the subject matter of the record.
`A record in this system of records may be disclosed, as a routine use, to a contractor of the Agency having need
`for the information in order to perform a contract. Recipients of information shall be required to comply with the
`requirements of the Privacy Act of 1974, as amended, pursuant to 5 U.S.C. 552a(m).
`A record related to an International Application filed under the Patent Cooperation Treaty in this system of
`records may be disclosed, as a routine use, to the International Bureau of the World Intellectual Property
`Organization, pursuant to the Patent Cooperation Treaty.
`Arecordin this system of records may be disclosed, as a routine use, to an other federal agency for purposes
`of National Security review (35 U.S.C. 181) and for review pursuant to the Atomic Energy Act (42 U.S.C. 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 of records conducted by GSA aspart of that agency's responsibility to
`recommend improvements in records managementpractices and programs, under authority of 44 U.S.C. 2904 and
`2906. Such disclosure shall be made in accordance with the GSA requlations governing inspection of records for this
`purpose, and any other relevant(i-e., GSA or Commerce) directive. Such disclosure shall not be used to make
`determinations aboutindividuals.
`
`A record from this system of records may be disclosed, as a routine use, to the public after either publication of
`the application pursuant to 35 U.S.C. 122(b) or issuance of a patent pursuant to 35 U_S_C_ 151. Further, a record
`may be disclosed, subject to the limitations of 37 CFR 1.14, as a routine use, to the public if the record wasfiled in an
`application which became abandonedor in which the proceedings were terminated and which application 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,if the USPTO becomes awareof a violation or potential violation of law or regulation.
`
`