PTO/SB/02LR Declaration Supplemental Sheet for Legal Representatives

Doc Code:

PTO/SB/2LR (02-07)
Approved for use through XX/XX/XXXX. OMB 0651-0032
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control number.

DECLARATION Supplemental Sheet
For Legal Representatives (35 U.S.C. 117) On Behalf of A Deceased or Incapacitated Inventor
Enter Deceased or Incapacitated Inventor’s Name ______________________________________

Name of Legal Representative:

A petition has been filed for this non-signing legal representative

Given Name (first and middle (if any))

Family Name or Surname

Legal Representative’s
Signature
Residence: City

Page______ of ______

Date
State

Country

Citizenship

Mailing Address
Mailing Address
City

State

Zip

Country

A petition has been filed for this non-signing legal representative

Name of Additional Legal Representative, if any:
Given Name (first and middle (if any))

Family Name or Surname

Legal Representative’s
Signature
Residence: City

State

Country

Citizenship

Mailing Address
Mailing Address
State

City

Zip

A petition has been filed for this non-signing legal representative

Name of Additional Legal Representative, if any:
Given Name (first and middle (if any))

Family Name or Surname

Legal Representative’s
Signature
Residence: City

Country

Date
State

Country

Citizenship

Mailing Address
Mailing Address
City

State

Zip

Country

This collection of information is required by 35 U.S.C. 117 and 37 CFR 1.42, 1.43, 1.63 and 1.64(b). The information is required to obtain or retain a benefit 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 1.14. This collection is estimated
to take 21 minutes to complete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the
individual case. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden, should be sent to the Chief
Administrative Officer, 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 FORMS 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.

OMB Clearance and PRA Burden Statement for PTO/SB/2LR
This collection of information is required by 37 CFR 1.137. The information is required to obtain or retain a benefit 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, 1.14 and 41.6. This form is estimated to
take 21 minutes to complete, including gathering, preparing, and submitting the completed form to the USPTO. Time will vary depending upon the
individual case. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden, should be sent
to the Chief Administration Officer, 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 FORMS TO THIS ADDRESS. SEND TO: Mail Stop Petition, Commissioner for Patents, P.O. Box 1450, Alexandria, VA
22313-1450.

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. The United States Patent and Trademark Office (USPTO) collects this information under authority of 5 CFR 339.205.
The information in this system of records is used to manage all records of applicant including name, citizenship, residence, post office address and
other information pertaining to the applicant's activities in connection with the invention for which a patent is sought. Statements containing various
kinds of information with respect to inventors who are deceased or incapacitated, or who are unavailable or unwilling to make application for patent.
The information obtain is protected from disclosure to third parties in accordance with the Privacy Act.
However, routine uses of this information may include disclosure to the following: to law enforcement and investigation in the event that the system
of records indicates a violation or potential violation of law; to a Federal, state, local, or international agency, in response to its request; to an agency,
organization, or individual for the purpose of performing audit or oversight operations as authorized by law; to non-federal personnel under contract
to the agency; to a court for adjudication and litigation; to the Department of Justice for Freedom of Information Act (FOIA) assistance; to members of
congress working on behalf of an individual; to the Office of Personnel Management (OPM) for personnel research purposes; to National Archives and
Records Administration for inspection of records; and to the Office of Management and Budget (OMB)for legislative coordination and clearance.
Failure to provide any part of the requested information may result in an inability to process requests for access and information. The applicable
Privacy Act System of Records Notice for this information is COMMERCE/PAT-TM-7 Patent Application Files, available at Federal Register /Vol. 78, No.
61 / Friday, March 29, 2013 /Notices 19243. https://www.govinfo.gov/content/pkg/FR-2013-03-29/pdf/2013-07341.pdf