PTO/AIA/04 Substitute Statement in Lieu of an Oath or Declaration f

Doc code: Oath
Document Description: Oath or declaration filed

PTO/$,$ (06-15)
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.



SUBSTITUTE STATEMENT IN LIEU OF AN OATH OR DECLARATION FOR

PLANT PATENT APPLICATION
(35 U.S.C. 115(d) AND 37 CFR 1.64)




Title of
Invention

This statement is directed to:
The attached application,

OR
United States application number ____________________ filed on ___________________.

LEGAL NAME of inventor to whom this substitute statement applies:
(E.g., Given Name (first and middle (if any)) and Family Name or Surname)

Residence (except for a deceased or legally incapacitated inventor):
City

State

Country

Mailing Address (except for a deceased or legally incapacitated inventor):

City

Zip

State

Country

I have asexually reproduced the plant to which this application applies;
The plant was found in a cultivated area (check this box for a newly found plant only);
I believe the above-named inventor or joint inventor to be the original inventor or an original joint inventor of a claimed invention
in the application.
The above-identified application was made or authorized to be made by me.
I hereby acknowledge that any willful false statement made in this statement is punishable under 18 U.S.C. 1001 by fine or
imprisonment of not more than five (5) years, or both.
Relationship to the inventor to whom this substitute statement applies:
Legal Representative (for deceased or legally incapacitated inventor only),
Assignee,
Person to whom the inventor is under an obligation to assign,
Person who otherwise shows a sufficient proprietary interest in the matter (petition under 37 CFR 1.46 is required), or
Joint Inventor.
[Page 1 of 2]
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 21 minutes 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.

PTO/$,$ (06-15)
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.






SUBSTITUTE STATEMENT

Circumstances permitting execution of this substitute statement:
Inventor is deceased,
Inventor is under legal incapacity,
Inventor cannot be found or reached after diligent effort, or
Inventor has refused to execute the oath or declaration under 37 CFR 1.63.
If there are joint inventors, please check the appropriate box below:
An application data sheet under 37 CFR 1.76 (PTO/$,$/14 or equivalent) naming the entire inventive entity has been
or is currently submitted.

OR
An application data sheet under 37 CFR 1.76 (PTO/$,$/14 or equivalent) has not been submitted. Thus, a Substitute
Statement Supplemental Sheet (PTO/$,$ or equivalent) naming the entire inventive entity and providing inventor
information is attached. See 37 CFR 1.64(b).

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.
PERSON EXECUTING THIS SUBSTITUTE STATEMENT:
Name:

Date (Optional):

Signature:
$33/,&$171$0($1'7,7/(2)3(5621EXECUTING THIS SUBSTITUTE STATEMENT:
,IWKHDSSOLFDQWLVDMXULVWLFHQWLW\OLVWWKHDSSOLFDQWQDPHDQGWKHWLWOHRIWKHVLJQHU:
$SSOLFDQW1DPH:
7LWOHRI3HUVRQ([HFXWLQJ
7KLV6XEVWLWXWH6WDWHPHQW
7KHVLJQHUZKRVHWLWOHLVVXSSOLHGDERYHLVDXWKRUL]HGWRDFWRQEHKDOIRIWKHDSSOLFDQW
Residence (unless provided in an application data sheet, PTO/SB/14 or equivalent):
City

Country

State

Mailing Address (unless provided in an application data sheet, PTO/SB/14 or equivalent)

City
Country
Zip
State
Note: Use an additional PTO/$,$ form for each inventor who is deceased, legally incapacitated, cannot be found or
reached after diligent effort, or has refused to execute the oath or declaration under 37 CFR 1.63.
[Page 2 of 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 process
and/or examine your submission, which may result in termination of proceedings, 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 became abandoned or in which the proceedings were
terminated and which application is 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.