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DECLARATION (37 CFR 1.63) FOR UTILITY OR DESIGN APPLICATION USING AN
APPLICATION DATA SHEET (37 CFR 1.76)
Title ofInvention

As the below named inventor, I hereby declare that:
This declaration
is directed to:

The attached application, or
United States application or PCT international application number ____________________BBBB
filed on ________________________________

The above-identified application was made or authorized to be made by me.

I believe that I am the original inventor or an original joint inventor of a claimed invention in the application.

I hereby acknowledge that any willful false statement made in this declaration is punishable under 18 U.S.C. 1001
by fine or imprisonment of not more than ILYH(5) years, or both.

WARNING:
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. 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 theUSPTO. Petitioner/applicant is advised that the record of a patent application is available to the public after publication of theapplication (unless a non-publication request in compliance with 37 CFR 1.213(a) is made in the application) or issuance of apatent. Furthermore, the record from an abandoned application may also be available to the public if the application isreferenced in a published application or an issued patent (see 37 CFR 1.14). 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.

LEGAL NAME OF INVENTOR

Inventor: ___________________________________________________

Date (Optional) :_______________________

Signature: ________________________________________________________________________________________
Note: An application data sheet (PTO/SB/14 or equivalent), including naming the entire inventive entity, must accompany this formRUPXVWKDYH
EHHQSUHYLRXVO\ILOHG. Use an additional PTO/A,$ form for each additional inventor.
This collection of information is required by 35 U.S.C. 115 and 37 CFR 1.63. The information is required to obtain or retain a benefit by the public which is to file (andby the USPTO to 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 1 minute tocomplete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the individual case. Anycomments on the amount of time you require to complete this form and/or suggestions for reducing this burden, should be sent to the Chief Information Officer, U.S.
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THIS ADDRESS. SEND TO: Commissioner for Patents, P.O. Box 1450, Alexandria, VA 22313-1450.
If you need assistance in completing the form, call 1-800-PTO-9199 and select option 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 patent. Accordingly,
pursuant to the requirements of the Act, please be advised that: (1) the general authority for thecollection 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
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The information provided by you in this form will be subject to the following routine uses:
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The information on this form will be treated confidentially to the extent allowed under theFreedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records fromthis system of records may be disclosed to the Department of Justice to determine whether
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