Form PTO/AIA/01 Declaration (37 CFR 1.63) for Utility or Design Applicat

PTO/AIA/01 (06-12)
Approved for use through 05/31/2024. 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 displays a valid OMB control number.

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

Title of
Invention

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 ________________________
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 five (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 the
USPTO. Petitioner/applicant is advised that the record of a patent application is available to the public after publication of the
application (unless a non-publication request in compliance with 37 CFR 1.213(a) is made in the application) or issuance of a
patent. Furthermore, the record from an abandoned application may also be available to the public if the application is
referenced 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/AIA/14 or equivalent), including naming the entire inventive entity, must accompany this form or must
have been previously filed. Use an additional PTO/AIA/01 form for each additional inventor.
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995, unless the information collection has a
currently valid OMB Control Number. The OMB Control Number for this information collection is 0651-0032. Public burden for this form is
estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information collection. Send comments regarding this burden estimate or any
other aspect of this information collection, including suggestions for reducing this burden to the Chief Administrative Officer, United States Patent
and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email InformationCollection@uspto.gov. DO NOT SEND FEES OR
COMPLETED FORMS TO THIS ADDRESS. If filing this completed form by mail, 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. The United States
Patent and Trademark Office (USPTO) collects the information in this record under authority of 35
U.S.C. 2. The USPTO’s system of records is used to manage all applicant and owner information
including name, citizenship, residence, post office address, and other information with respect to
inventors and their legal representatives pertaining to the applicant's/owner’s activities in connection
with the invention for which a patent is sought or has been granted. The applicable Privacy Act
System of Records Notice for the information collected in this form is COMMERCE/PAT-TM-7 Patent
Application Files, available in the Federal Register at 78 FR 19243 (March 29, 2013). https://
www.govinfo.gov/content/pkg/FR-2013-03-29/pdf/2013-07341.pdf
Routine uses of the information in this record may include disclosure to: 1) law enforcement, in the
event that the system of records indicates a violation or potential violation of law; 2) a Federal,
state, local, or international agency, in response to its request; 3) a contractor of the USPTO having
need for the information in order to perform a contract; 4) the Department of Justice for
determination of whether the Freedom of Information Act (FOIA) requires disclosure of the record; 5)
a Member of Congress submitting a request involving an individual to whom the record pertains,
when the individual has requested the Member’s assistance with respect to the subject matter of the

record; 6) a court, magistrate, or administrative tribunal, in the course of presenting evidence,
including disclosures to opposing counsel in the course of settlement negotiations; 7) the
Administrator, General Services Administration (GSA), or their designee, during an inspection of
records conducted by GSA under authority of 44 U.S.C. 2904 and 2906, in accordance with the
GSA regulations and any other relevant (i.e., GSA or Commerce) directive, where such disclosure
shall not be used to make determinations about individuals; 8) another federal agency for purposes
of National Security review (35 U.S.C. 181) and for review pursuant to the Atomic Energy Act (42
U.S.C. 218(c)); 9) the Office of Personnel Management (OPM) for personnel research purposes; and
9) the Office of Management and Budget (OMB) for legislative coordination and clearance.
If you do not furnish the information requested on this form, the USPTO may not be able to
and/or examine your submission, which may result in termination of proceedings,
process
abandonment of the application, and/or expiration of the patent.

Additional Uses

Additional USPTO uses of the information in this record may include disclosure to: 1) the
International Bureau of the World Intellectual Property Organization, if the record is related
to an international application filed under the Patent Cooperation Treaty; 2) the public i)
after publication of the application pursuant to 35 U.S.C. 122(b), ii) after issuance of a
patent pursuant to 35 U.S.C. 151, iii) if the record was filed in an application which
abandoned or in which the proceedings were terminated and which application is
became
referenced by either a published application, an application open to public inspections, or
an issued patent, or iv) without publication of the application or patent under the specific
circumstances provided for by 37 CFR 1.14(a)(1)(v)-(vii); and/or 3) the National Archives
and Records Administration, for inspection of records.