PTO/(06-1Approved for use through 01/31/2014. OMB 0651-0032U.S. Patent and Trademark Office; U.S. DEPARTMENT <strong>OF</strong> COMMERCEUnder the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control num<strong>be</strong>r.SUBSTITUTE STATEMENT SUPPLEMENTAL SHEETNote: List entire inventive entity in the desired order.Legal Name of Joint Inventor:(E.g., Given Name (first and middle (if any)) and Family Name or Surname)INVENTOR(S)Supplemental Sheet (for PTO/)Page _ofInventor’sSignatureDate (Optional)Residence: City State CountryMailing AddressCity State Zip CountryLegal Name of Joint Inventor:(E.g., Given Name (first and middle (if any)) and Family Name or Surname)Inventor’sSignatureDate (Optional)Residence: City State CountryMailing AddressCity State Zip CountryLegal Name of Joint Inventor:(E.g., Given Name (first and middle (if any)) and Family Name or Surname)Inventor’sSignatureDate (Optional)Residence: City State CountryMailing AddressCity State Zip CountryThis 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 <strong>be</strong>nefit by the public which is to file(and by 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 21minutes to complete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the individualcase. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden, should <strong>be</strong> sent to the Chief InformationOfficer, U.S. Patent and Trademark Office, U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313-1450. DO NOT SEND FEES OR COMPLETED<strong>FOR</strong>MS TO 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 (1-800-786-9199) and select option 2.
Sheet No. . . . . . . .Box No. VIII (iv) DECLARATION: INVENTORSHIP (only for the purposes of the designation of the United States of America)The declaration must conform to the following standardized wording provided for in Section 214; see Notes to Boxes Nos. VIII, VIII (i) to (v)(in general) and the specific Notes to Box No.VIII (iv). If this Box is not used, this sheet should not <strong>be</strong> included in the request.Declaration of inventorship (Rules 4.17(iv) and 51bis.1(a)(iv))for the purposes of the designation of the United States of America:I hereby declare that I <strong>be</strong>lieve I am the original, first and sole (if only one inventor is listed <strong>be</strong>low) or joint (if more than one inventoris listed <strong>be</strong>low) inventor of the subject matter which is claimed and for which a patent is sought.This declaration is directed to the international application of which it forms a part (if filing declaration with application).This declaration is directed to international application No. PCT/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (if furnishing declaration pursuantto Rule 26ter).I hereby declare that my residence, mailing address, and citizenship are as stated next to my name.I hereby state that I have reviewed and understand the contents of the above-identified international application, including the claimsof said application. I have identified in the request of said application, in compliance with PCT Rule 4.10, any claim to foreign priority,and I have identified <strong>be</strong>low, under the heading “Prior Applications,” by application num<strong>be</strong>r, country or Mem<strong>be</strong>r of the World TradeOrganization, day, month and year of filing, any application for a patent or inventor’s certificate filed in a country other than the UnitedStates of America, including any PCT international application designating at least one country other than the United States of America,having a filing date <strong>be</strong>fore that of the application on which foreign priority is claimed.Prior Applications: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I hereby acknowledge the duty to disclose information that is known by me to <strong>be</strong> material to patentability as defined by37 C.F.R. § 1.56, including for continuation-in-part applications, material information which <strong>be</strong>came available <strong>be</strong>tween the filing dateof the prior application and the PCT international filing date of the continuation-in-part application.I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and <strong>be</strong>liefare <strong>be</strong>lieved to <strong>be</strong> true; and further that these statements were made with the knowledge that willful false statements and the like somade are punishable by fine or imprisonment, or both, under Section 1001 of Title 18 of the United States Code and that such willfulfalse statements may jeopardize the validity of the application or any patent issued thereon.Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Residence: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(city and either US state, if applicable, or country)Mailing Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Citizenship: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inventor’s Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(The signature must <strong>be</strong> that of the inventor, not that of the agent)Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Residence: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(city and either US state, if applicable, or country)Mailing Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Citizenship: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inventor’s Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(The signature must <strong>be</strong> that of the inventor, not that of the agent)This declaration is continued on the following sheet, “Continuation of Box No. VIII (iv)”.Form PCT/RO/101 (declaration sheet (iv)) (July 2012)See Notes to the request form
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