NASA Dryden Flight Research Center

Technology Utilization Office

P.O. Box 273, Mail Stop D-2131

Edwards, CA 93523-3119

NASA Glenn Research Center

Attn: Patent Counsel

Mail Stop 500-118

Cleveland, Ohio 44135

NASA Goddard Space Flight Center

Attn: Patent Counsel

Greenbelt Road - Mail Stop 503

Greenbelt, MD 20771

NASA Headquarters\
Office of the General Counsel

Attn: Agency Counsel for Intellectual Property

Suite 9T39\
300 E. Street, S.W.\
Washington, D.C. 20546

Jet Propulsion Lab

Attn: Patricia McGuire

4800 Oak Grove Drive; Mail Stop 126-256

Pasadena, Ca 91109-8099

NASA Johnson Space Center

Attn: Patent Counsel

2101 NASA Road 1 - Mail Stop HA

Houston, TX 77058-3696

NASA John F. Kennedy Space Center

Attn: Patent Counsel

Mail Code: CC-A

Kennedy Space Center, FL 32899

NASA Langley Research Center

Patent Counsel Office

3 Langley Blvd. - Mail Stop 212

Hampton, VA 23681-2199

NASA Marshall Space Flight Center

Attn: Patent Counsel

Mail Stop LS01

MSFC, Alabama 35812

NASA Stennis Space Center

Technology Transfer Office

Mail Stop JA00

Stennis Space Center, MS 39829-6000

NASA contracts, grants, cooperative agreements, and subcontracts
(Funding Agreements) with small businesses, colleges, universities, and
nonprofit organizations require each Contractor/Grantee/ Subcontractor
(C/G/S) to elect in writing whether or not to retain title to any
subject invention within 2 years of its disclosure to NASA (this period
may be shortened if a statutory bar exists). A C/G/S who elects to
retain title to a subject invention must file its initial patent
application within 1 year of electing title. The C/G/S may elect or
decline title by providing the following information and checking the
appropriate box below. This Election form may be submitted separately to
the address provided above, or may be submitted with a New Technology
Summary Report form to the address provided with the form. Go to
[http://invention.nasa.gov](http://invention.nasa.gov/) for access to
forms.

Submitting C/G/S Name and Address:

C/G/S New Technology Representative:      

Election Submitted by      

(if not New Technology Representative):

Contact Telephone Number: (   )     -      Contact Email Address:      

NASA Funding Agreement Number:       Funding Agreement Completion Date:
  /  /    

Title of Funded Activity:      

## NASA Project Manager/\*COTR or Grant Monitor:      

**Please provide the following information for all subject inventions
for which you wish to make an election. If additional space is required,
include an attachment.**

+---+----------------------+--------+-----------+---------+-----+-----+
|   | [Title of Subject    | [In    | [Has      | [Patent | [El | [El |
|   | Invention            | ternal | Subject   | App     | ect | ect |
|   | and]{.underline}     | D      | Invention | licatio | to  | to  |
|   |                      | ocket] | Been      | n]{.und | Ret | D   |
|   | [Name of             | {.unde | Disclosed | erline} | ain | ecl |
|   | Inve                 | rline} | to        |         | Tit | ine |
|   | ntor(s)]{.underline} |        | NASA?]{.u | [Filed  | le] | Tit |
|   |                      | [N     | nderline} | ?]{.und | {.u | le] |
|   |                      | umber] |           | erline} | nde | {.u |
|   |                      | {.unde |           |         | rli | nde |
|   |                      | rline} |           |         | ne} | rli |
|   |                      |        |           |         |     | ne} |
+---+----------------------+--------+-----------+---------+-----+-----+
| - |                      |        | Yes       | Yes     |     |     |
|   |                      |        |           |         |     |     |
|   |                      |        | Date      | Filing  |     |     |
|   |                      |        | reported: | Date    |     |     |
|   |                      |        |           |         |     |     |
|   |                      |        |           |   /     |     |     |
|   |                      |        |  /  /     |   /     |     |     |
|   |                      |        |           |         |     |     |
|   |                      |        | If not,   | Serial  |     |     |
|   |                      |        | please    | No.     |     |     |
|   |                      |        | attach    |         |     |     |
|   |                      |        | hereto.   |         |     |     |
|   |                      |        |           |  /      |     |     |
+---+----------------------+--------+-----------+---------+-----+-----+
| - |                      |        | Yes       | Yes     |     |     |
|   |                      |        |           |         |     |     |
|   |                      |        | Date      | Filing  |     |     |
|   |                      |        | reported: | Date    |     |     |
|   |                      |        |           |         |     |     |
|   |                      |        |           |   /     |     |     |
|   |                      |        |  /  /     |   /     |     |     |
|   |                      |        |           |         |     |     |
|   |                      |        | If not,   | Serial  |     |     |
|   |                      |        | please    | No.     |     |     |
|   |                      |        | attach    |         |     |     |
|   |                      |        | hereto.   |         |     |     |
|   |                      |        |           |  /      |     |     |
+---+----------------------+--------+-----------+---------+-----+-----+

This election form must be signed by an authorized representative of the
contractor/grantee/ subcontractor with authority to make the election
above.

     

**Name and Title of Authorized Official**

**  /   /    **

**Signature Date**