Form PTO/AIA/05 Reissue Application Declaration by the Inventor


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Approved for use through XX/XX/XXXX. OMB 0651-0033
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 displays a valid OMB control number.

Docket Number (Optional)

REISSUE APPLICATION DECLARATION BY THE INVENTOR

I hereby declare that: 
Each inventor’s residenceDQG mailing address are stated below next to their name. 
I believe ,DPWKHRULJLQDOLQYHQWRURUDQRULJLQDOMRLQWLQYHQWRU of the subject matter which is described and claimed
in patent number 
, granted
and for which a
reissue patent is sought on the invention titled _______BB_________________________________________________,
,

the specification of which
is attached hereto.
was filed on

as reissue application number

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I KHUHE\DFNQRZOHGJHWKDWDQ\ZLOOIXOIDOVHVWDWHPHQWPDGHLQWKLVGHFODUDWLRQLVSXQLVKDEOHXQGHU1886&E\ILQH
RULPSULVRQPHQWRIQRWPRUHWKDQILYH\HDUVRUERWK.
I believe the original patent to be wholly or partly inoperative or invalid, for the reasons described
below. (Check all boxes that apply.)
by reason of a defective specification or drawing.
by reason of the patentee claiming more or less than he had the right to claim in the patent.
by reason of other errors.
At least one error upon which reissue is based is described below.If the reissue is a broadening
reissue, DFODLPWKDWWKHDSSOLFDWLRQVHHNVWREURDGHQPXVWEHLGHQWLILHG:

[Page 1 of 2]

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PTO/$,$5 (0-)
Approved for use through 03/31/2023. OMB 0651-0033
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 displays a valid OMB control number.

Docket Number (Optional)
(REISSUE APPLICATION DECLARATION BY THE INVENTOR, page 2)

Note: To appoint a power of attorney, use form PTO/AIA/81.
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/HJDO name of sole or first inventor ((J*LYHQ1DPHILUVWDQGPLGGOHLIDQ\DQG)DPLO\1DPHRU6XUQDPH)

Inventor's 6ignature

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Residence&LW\6WDWH&RXQWU\
Mailing Address

&LW\6WDWH=LS&RXQWU\

Additional joint inventors are named on WKHBBBBBBVXSSOHPHQWDO sheets PTO/$,$/DWWDFKHGKHUHWR.

[Page 2 of 2]

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