PTO Form 1963 (Rev 5/2006)
`
`OMB No. 0651-0055 (Exp 10/31/2008)
`
`Combined Declaration of Use In Commerce & Application For
`Renewal of Registration of A Mark Under Sections 8 & 9
`
`The table below presents the data as entered.
`
`Input Field
`
`Entered
`
`REGISTRATION NUMBER
`
`1761828
`
`REGISTRATION DATE
`
`SERIAL NUMBER
`
`MARK SECTION
`
`MARK
`
`OWNER SECTION (current)
`
`03/30/1993
`
`74213533
`
`MEDICA
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`ZIP/POSTAL CODE
`
`COUNTRY
`
`OWNER SECTION (proposed)
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`ZIP/POSTAL CODE
`
`COUNTRY
`
`EMAIL
`
`ATTORNEY SECTION
`
`NAME
`
`FIRM NAME
`
`MEDICA HEALTH PLAN
`
`5601 SMETANA DRIVE
`
`MINNETONKA
`
`MN
`
`55343
`
`US
`
`MEDICA HEALTH PLAN
`
`5601 SMETANA DRIVE
`
`MINNETONKA
`
`MN
`
`55343
`
`US
`
`eric.paulsrud@leonard.com
`
`Eric D. Paulsrud
`
`Leonard, Street and Deinard
`
`

`
`STREET
`
`CITY
`
`STATE
`
`ZIP/POSTAL CODE
`
`COUNTRY
`
`PHONE
`
`FAX
`
`EMAIL
`
`150 South 5th Street Suite 2300
`
`Minneapolis
`
`MN
`
`55402
`
`USA
`
`612-335-1448
`
`612-335-1657
`
`eric.paulsrud@leonard.com
`
`AUTHORIZED TO COMMUNICATE VIA
`E-MAIL
`
`Yes
`
`DOCKET NUMBERS
`
`OTHER APPOINTED ATTORNEY(S)
`
`54401.00040
`
`Doris Yock
`
`GOODS AND/OR SERVICES SECTION
`
`INTERNATIONAL CLASS
`
`KEEP EXISTING GOODS AND/OR
`SERVICES
`
`042
`
`YES
`
`SPECIMEN(cid:160)FILE NAME(S)
`
`\\ticrs\EXPORT7\IMAGEOUT7
`\742\135\74213533\xml1\S8 90002.JPG
`
`SPECIMEN DESCRIPTION
`
`Member card for services
`
`PAYMENT SECTION
`
`NUMBER OF CLASSES
`
`NUMBER OF CLASSES PAID
`
`SUBTOTAL AMOUNT
`
`GRACE PERIOD
`
`TOTAL AMOUNT
`
`SIGNATURE SECTION
`
`SIGNATURE
`
`SIGNATORY NAME
`
`SIGNATORY DATE
`
`1
`
`1
`
`500
`
`200
`
`700
`
`/Eric D. Paulsrud/
`
`Eric D. Paulsrud
`
`09/26/2003
`
`SIGNATORY POSITION
`
`Attorney for Applicant
`
`FILING INFORMATION
`
`SUBMIT DATE
`
`Fri Sep 26 11:41:28 EDT 2003
`
`

`
`TEAS STAMP
`
`USPTO/S08N09-2099820712-2
`0030926114128714012-17618
`28-20093c03e352d32266cca2
`42f16eefaf058CC767-200309
`26113845867085
`
`

`
`PTO Form 1963 (Rev 5/2006)
`
`OMB No. 0651-0055 (Exp 10/31/2008)
`
`Combined Declaration of Use In Commerce & Application For Renewal of
`Registration of A Mark Under Sections 8 & 9
`To the Commissioner for Trademarks:
`
`REGISTRATION NUMBER:(cid:160)1761828
`REGISTRATION DATE:(cid:160)03/30/1993
`
`MARK: (cid:160)MEDICA
`
`The owner, MEDICA HEALTH PLAN, residing at 5601 SMETANA DRIVE , MINNETONKA, MN US
`55343, is using the mark in commerce on or in connection with the goods and /or services as follows:
`
`For International Class 042, the owner is using or is using through a related company the mark in
`commerce on or in connection with all goods and/or services listed in the existing registration.
`
`The owner is submitting one specimen for each class showing the mark as used in commerce on or in
`connection with any item in the class of listed goods and/or services , consisting of a(n) Member card for
`services.
`Specimen-1
`
`The registrant hereby appoints Eric D. Paulsrud and Doris Yock of (cid:160)Leonard, Street and Deinard, 150
`South 5th Street Suite 2300, Minneapolis, MN USA 55402 to submit this Combined Declaration of Use In
`Commerce & Application For Renewal of Registration of A Mark Under Sections 8 & 9 on behalf of the
`registrant. The attorney docket/reference number is 54401.00040.
`
`A fee payment in the amount of $700 will be submitted with the form, representing payment for 1
`class(es), plus any additional grace period fee, if necessary.
`
`Declaration
`
`Section 8: Declaration of Use in Commerce
`The owner is using or is using through a related company the mark in commerce on or in connection with
`the goods/services identified above, as evidenced by the attached specimen(s) showing the mark as used in
`commerce.
`
`Section 9: Application for Renewal
`The registrant requests that the registration be renewed for the goods and/or services identified above.
`
`The undersigned being hereby warned that willful false statements and the like are punishable by fine or
`imprisonment, or both, under 18 U.S.C. Section 1001, and that such willful false statements and the like
`may jeopardize the validity of this document, declares that he/she is properly authorized to execute this
`document on behalf of the Owner; and all statements made of his/her own knowledge are true and that all
`statements made on information and belief are believed to be true.
`
`

`
`Signature: /Eric D. Paulsrud/(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)Date: 09/26/2003
`Signatory's Name: Eric D. Paulsrud
`Signatory's Position: Attorney for Applicant
`
`Mailing Address:
`(cid:160)(cid:160)(cid:160)Leonard, Street and Deinard
`(cid:160)(cid:160)(cid:160)150 South 5th Street Suite 2300
`(cid:160)(cid:160)(cid:160)Minneapolis, MN 55402
`
`RAM Sale Number: 767
`RAM Accounting Date: 09/26/2003
`
`Serial Number: 74213533
`Internet Transmission Date: Fri Sep 26 11:41:28 EDT 2003
`TEAS Stamp: USPTO/S08N09-2099820712-2003092611412871
`4012-1761828-20093c03e352d32266cca242f16
`eefaf058CC767-20030926113845867085
`
`

`
`
`
`Rx_ BIN: H Rx PCN: “
`ID. ‘U16
`NAME: ERiC D FAULSRUD
`NAME: TPAULSRUD
`NAME: —fi PAULSRUD
`
`-00
`-01
`-02
`
`ACCOUNT: B?41'fi
`CARE TYPE: MEDICA CHOICE SELECT
`svc T"r'PE: MEDICAL
`COPAYS RX
`URGI
`
`$11.00
`$15.00
`
`ER
`
`$30.00
`
`DV
`
`$15.00
`
`Issue Date: D4!15.~‘D3
`
`
`

`
`FEE RECORD SHEET
`
`Registration Number:
`
`1761828
`
`Serial Number:
`
`74213 533
`
`RAM Sale Number: 767
`
`Total Fees:
`
`$700
`
`RAM Accounting Date: 20030926
`
`Transaction
`
`Transaction
`Date
`
`Fee per
`Class
`
`Total
`Number
`of Classes 1
`
`§8 affidavit
`Application for Renewal (§9)
`
`Grace period for §8
`Grace period for renewal
`
`09/26/2003
`09/26/2003
`
`09/26/2003
`09/26/2003
`
`$100
`$400
`
`$100
`$100
`
`$100
`$400
`
`$100
`$100