PTO Form 1963 (Rev 5/2006)
`
`OMB No. 0651-0055 (Exp 07/31/2018)
`
`Combined Declaration of Use and/or Excusable
`Nonuse/Application for Renewal of Registration of a Mark under
`Sections 8 & 9
`
`The table below presents the data as entered.
`
`Entered
`
`Input Field
`
`REGISTRATION
`NUMBER
`
`REGISTRATION
`DATE
`
`1761828
`
`03/30/1993
`
`SERIAL NUMBER 74213533
`
`MARK SECTION
`
`MARK
`
`MEDICA
`
`ATTORNEY SECTION (new)
`
`NAME
`
`Eric D. Paulsrud
`
`FIRM NAME
`
`Leonard, Street and Deinard
`
`STREET
`
`CITY
`
`STATE
`
`150 SOUTH FIFTH STREET, SUITE 2300
`
`Minneapolis
`
`Minnesota
`
`POSTAL CODE
`
`55402
`
`COUNTRY
`
`PHONE
`
`FAX
`
`EMAIL
`
`United States
`
`612-335-1448
`
`612-335-1657
`
`eric.paulsrud@leonard.com
`
`AUTHORIZED TO
`COMMUNICATE VIA
`E-MAIL
`
`Yes
`
`DOCKET/REFERENCE
`NUMBER
`
`54401.00040
`
`OTHER APPOINTED
`ATTORNEY
`
`Ruth Rivard
`
`

`
`CORRESPONDENCE SECTION (current)
`
`NAME
`
`ERIC D. PAULSRUD
`
`FIRM NAME
`
`LEONARD, STREET AND DEINARD
`
`STREET
`
`CITY
`
`STATE
`
`150 SOUTH 5TH STREET SUITE 2300
`
`MINNEAPOLIS
`
`Minnesota
`
`POSTAL CODE
`
`55402
`
`COUNTRY
`
`PHONE
`
`FAX
`
`EMAIL
`
`United States
`
`(612)335-1448
`
`(612)335-1657
`
`eric.paulsrud@leonard.com
`
`AUTHORIZED TO
`COMMUNICATE VIA
`E-MAIL
`
`Yes
`
`CORRESPONDENCE SECTION (proposed)
`
`NAME
`
`ERIC D. PAULSRUD
`
`FIRM NAME
`
`LEONARD, STREET AND DEINARD
`
`STREET
`
`CITY
`
`STATE
`
`150 SOUTH FIFTH STREET, SUITE 2300
`
`MINNEAPOLIS
`
`Minnesota
`
`POSTAL CODE
`
`55402
`
`COUNTRY
`
`PHONE
`
`FAX
`
`EMAIL
`
`United States
`
`612-335-1448
`
`612-335-1657
`
`eric.paulsrud@leonard.com
`
`AUTHORIZED TO
`COMMUNICATE VIA
`E-MAIL
`
`Yes
`
`DOCKET/REFERENCE
`NUMBER
`
`54401.00040
`
`GOODS AND/OR SERVICES SECTION
`
`INTERNATIONAL
`CLASS
`
`042
`
`GOODS OR SERVICES comprehensive health care plans and health plan management services
`
`

`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)SPECIMEN FILE NAME(S)
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)ORIGINAL PDF
`FILE
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)CONVERTED PDF
`FILE(S)
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(3 pages)
`
`SPN0-2041548930-175010933_._MEDICA_-_specimen_-_web_site_-_07-
`DEC-2012.pdf
`
`\\TICRS\EXPORT16\IMAGEOUT16\742\135\74213533\xml1\S890002.JPG
`
`\\TICRS\EXPORT16\IMAGEOUT16\742\135\74213533\xml1\S890003.JPG
`
`\\TICRS\EXPORT16\IMAGEOUT16\742\135\74213533\xml1\S890004.JPG
`
`SPECIMEN
`DESCRIPTION
`
`Company web site advertising services
`
`OWNER SECTION (current)
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`MEDICA HEALTH PLAN
`
`5601 SMETANA DRIVE
`
`MINNETONKA
`
`Minnesota
`
`ZIP/POSTAL CODE
`
`55343
`
`COUNTRY
`
`United States
`
`OWNER SECTION (proposed)
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`MEDICA HEALTH PLAN
`
`401 Carlson Parkway, Mail Route CP250
`
`MINNETONKA
`
`Minnesota
`
`ZIP/POSTAL CODE
`
`55305
`
`COUNTRY
`
`United States
`
`LEGAL ENTITY SECTION (current)
`
`TYPE
`
`corporation
`
`STATE/COUNTRY OF
`INCORPORATION
`
`Minnesota
`
`LEGAL ENTITY SECTION (proposed)
`
`TYPE
`
`non-profit corporation
`
`PAYMENT SECTION
`
`NUMBER OF CLASSES 1
`
`NUMBER OF CLASSES
`PAID
`
`1
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)
`

`
`SUBTOTAL AMOUNT
`
`TOTAL FEE PAID
`
`500
`
`500
`
`SIGNATURE SECTION
`
`SIGNATURE
`
`/Eric D. Paulsrud/
`
`SIGNATORY'S NAME Eric D. Paulsrud
`
`SIGNATORY'S
`POSITION
`
`DATE SIGNED
`
`Attorney of record, Minnesota bar member
`
`12/07/2012
`
`SIGNATORY'S PHONE
`NUMBER
`
`612-335-1448
`
`PAYMENT METHOD
`
`CC
`
`SUBMIT DATE
`
`Fri Dec 07 17:58:14 EST 2012
`
`FILING INFORMATION
`
`TEAS STAMP
`
`USPTO/S08N09-204.154.89.3
`0-20121207175814607843-17
`61828-49095a02a232e92d60f
`47194133bfdb31f-CC-5188-2
`0121207175010933027
`
`

`
`PTO Form 1963 (Rev 5/2006)
`
`OMB No. 0651-0055 (Exp 07/31/2018)
`
`Combined Declaration of Use and/or Excusable Nonuse/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: MEDICA
`
`The owner, MEDICA HEALTH PLAN, non-profit corporation, having an address of
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)401 Carlson Parkway, Mail Route CP250
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)MINNETONKA, Minnesota 55305
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)United States
`is filing a Combined Declaration of Use and/or Excusable Nonuse/Application for Renewal of
`Registration of a Mark under Sections 8 & 9.
`
`For International Class 042, the mark is in use in commerce on or in connection with all goods/services, or
`to indicate membership in the collective membership organization, listed in the existing registration for
`this specific class: comprehensive health care plans and health plan management services ; or, the owner is
`making the listed excusable nonuse claim.
`
`The owner is submitting one(or more) specimen(s) showing the mark as used in commerce on or in
`connection with any item in this class, consisting of a(n) Company web site advertising services.
`
`Original PDF file:
`SPN0-2041548930-175010933_._MEDICA_-_specimen_-_web_site_-_07-DEC-2012.pdf
`Converted PDF file(s) (3 pages)
`Specimen File1
`Specimen File2
`Specimen File3
`The registrant's current Correspondence Information: ERIC D. PAULSRUD of (cid:160)LEONARD, STREET
`AND DEINARD
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)150 SOUTH 5TH STREET SUITE 2300
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)MINNEAPOLIS, Minnesota (MN) 55402
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)United States
`
`The registrant's proposed Correspondence Information: ERIC D. PAULSRUD of (cid:160)LEONARD, STREET
`AND DEINARD
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)150 SOUTH FIFTH STREET, SUITE 2300
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)MINNEAPOLIS, Minnesota (MN) 55402
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)United States
`The docket/reference number is 54401.00040.
`
`

`
`The phone number is 612-335-1448.
`
`The fax number is 612-335-1657.
`
`The email address is eric.paulsrud@leonard.com.
`The registrant hereby appoints Eric D. Paulsrud and Ruth Rivard of (cid:160)Leonard, Street and Deinard
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)150 SOUTH FIFTH STREET, SUITE 2300
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)Minneapolis, Minnesota 55402
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)United States
`to submit this Combined Declaration of Use and/or Excusable Nonuse/Application for Renewal of
`Registration of a Mark under Sections 8 & 9 on behalf of the registrant. The docket/reference number is
`54401.00040.
`
`The phone number is 612-335-1448.
`
`The fax number is 612-335-1657.
`
`The email address is eric.paulsrud@leonard.com.
`
`A fee payment in the amount of $500 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 and/or Excusable Nonuse in Commerce
`Unless the owner has specifically claimed excusable nonuse, the mark is in use in commerce on or in
`connection with the goods and/or services identified above, as evidenced by the attached specimen(s)
`showing the mark as used in commerce.
`
`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.
`
`Section 9: Application for Renewal
`The registrant requests that the registration be renewed for the goods/services/collective organization
`identified above.
`
`Signature: /Eric D. Paulsrud/(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)Date: 12/07/2012
`Signatory's Name: Eric D. Paulsrud
`Signatory's Position: Attorney of record, Minnesota bar member
`Signatory's Phone Number: 612-335-1448
`
`Mailing Address:
`(cid:160)(cid:160)(cid:160)Leonard, Street and Deinard
`
`

`
`(cid:160)(cid:160)(cid:160)150 SOUTH FIFTH STREET, SUITE 2300
`(cid:160)(cid:160)(cid:160)Minneapolis, Minnesota 55402
`
`Serial Number: 74213533
`Internet Transmission Date: Fri Dec 07 17:58:14 EST 2012
`TEAS Stamp: USPTO/S08N09-204.154.89.30-2012120717581
`4607843-1761828-49095a02a232e92d60f47194
`133bfdb31f-CC-5188-20121207175010933027
`
`

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`
`ROUTING SHEET TO POST REGISTRATION (PRU)
`
`Registration Number?
`
`1761323
`
`Serial Number:
`
`74213 533
`
`RAM Sale Number: 5188
`
`RAM Accounting Date: 20121210
`
`Total Fees:
`
`$500
`
`Note: Process in accordance with Post Registration Standard Operating Procedure (SOP)
`
`Transaction
`
`Transaction
`Date
`
`Fee per
`Class
`
`Number
`of Classes
`
`Number of
`Classes Paid
`
`§8 affidavit
`Application for Renewal (§9)
`
`20121207
`20121207
`
`$100
`$400
`
`Physical Location: 900 - FILE REPOSITORY (FRANCONIA)
`
`Lost Case Flag: False
`
`In TICRS (AM—FLG—IN—TICRS): True
`
`Transaction Date:
`
`20121207