Doc Code: MES.GIB
Document Description: Certification of Micro Entity Status (Gross Income Basis)

PTO/SB/15A (07-14)

CERTIFICATION OF MICRO ENTITY STATUS(GROSS INCOME BASIS)
Application Number or Control Number (if applicable):

Patent Number (if applicable):First Named Inventor:

Title of Invention:

The applicant hereby certifies the following—(1) SMALL ENTITY REQUIREMENT – The applicant qualifies as a small entity as defined in37 CFR 1.27.
(2) APPLICATION FILING LIMIT – Neither the applicant nor the inventor nor a joint inventor has
been named as the inventor or a joint inventor on more than four previously filed U.S. patentapplications, excluding provisional applications and international applications under the Patent
Cooperation Treaty (PCT) for which the basic national fee under 37 CFR 1.492(a) was not paid,
and also excluding patent applications for which the applicant has assigned all ownership rights,
or is obligated to assign all ownership rights, as a result of the applicant’s previous employment.
(3) GROSS INCOME LIMIT ON APPLICANTS AND INVENTORS – Neither the applicant nor theinventor nor a joint inventor, in the calendar year preceding the calendar year in which theapplicable fee is being paid, had a gross income, as defined in section 61(a) of the Internal
Revenue Code of 1986 (26 U.S.C. 61(a)), exceeding the “Maximum Qualifying Gross Income”
reported on the USPTO Web site at http://www.uspto.gov/patents/law/micro_entity.jsp which isequal to three times the median household income for that preceding calendar year, as mostrecently reported by the Bureau of the Census.
(4) GROSS INCOME LIMIT ON PARTIES WITH AN “OWNERSHIP INTEREST” – Neither theapplicant nor the inventor nor a joint inventor has assigned, granted, or conveyed, nor is under anobligation by contract or law to assign, grant, or convey, a license or other ownership interest in
the application concerned to an entity that, in the calendar year preceding the calendar year inwhich the applicable fee is being paid, had a gross income, as defined in section 61(a) of theInternal Revenue Code of 1986, exceeding the “Maximum Qualifying Gross Income” reported on
the USPTO Web site at http://www.uspto.gov/patents/law/micro_entity.jsp which is equal to threetimes the median household income for that preceding calendar year, as most recently reportedby the Bureau of the Census.
SIGNATURE by an authorized party set forth in 37 CFR 1.33(b)Signature
Name
Date

Telephone

Registration No.

There is more than one inventor and I am one of the inventors who are jointly identified as the applicant. The required
additional certification form(s) signed by the other joint inventor(s) are included with this form.

Privacy Act Statement
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with yoursubmission of the attached form related to a patent application or patent. Accordingly, pursuant to the requirements ofthe 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 theU.S. Patent and Trademark Office is to process and/or examine your submission related to a patent application orpatent. If you do not furnish the requested information, the U.S. Patent and Trademark Office may not be able toprocess and/or examine your submission, which may result in termination of proceedings or abandonment of theapplication or expiration of the patent.
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 the Freedom ofInformation Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from this system of records may
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