Provisional Application for Patent Cover Sheet

• Legal Form Number: SB/16
• Court: United States Patent and Trademark Office
• Section: United States Patent and Trademark Office

PTO/SB/16 (12-22)

Approved for use through 05/31/2024. OMB 0651-0032

U.S. Patent and Trademark Office; U.S. D EPARTMENT OF COM MERCE

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

PROVISIONAL APPLICATION FOR PATENT COVER SHEET – Page 1 o f 2

This is a r equ es t for fili ng a PROVI SIONAL AP PLI CATION FOR P ATENT und er 3 7 CFR 1.53(c).

Priority Mail Express® Label No. ___________ _ ____ ___ ___ ____ ___ ___ ____ __________________________

INVENTOR(S)

Given Name (first and m iddle [if any]) Family Name or Surname

Residence

(City and either S tate or Foreign Country )

Additional inve ntors are being named on the __________________ sepa rately numbered sheets a ttached hereto.

TITLE OF THE INV ENTIO N (5 00 char acte rs max):

Direct all correspondence to: CORRESPONDENCE ADDRESS

The address corresponding to Customer Number:

OR

Firm or

Individua l Name

Address

City

State

Zip

Country

Telephone

Email

ENCLOSED APPLICATION PARTS (check all that apply)

Application Data Sheet. S ee 37 CFR 1.76.

CD(s), Number of CDs _________________________________

Drawing(s) Number of Sheets __________________

Other (specify) _______________________________________

Specification (e.g. , description of the invention) Number of Page s __________________

Fees Due: Filing Fee of $300 ($120 for small entity) ($60 for micro entity). If the specification and drawings exceed 100 sheets of paper,

an application size fee is also due, which is $420 ($168 for small entity) ($84 for micro entity) for each additional 50 sheets or fraction

thereof. See 35 U.S.C. 41(a)(1)(G) and 37 CFR 1.16(s).

METHOD OF PAYMENT OF THE FILING FEE AND APPLICATION SIZE FEE FOR THIS PROVISIONAL APPLICATION FOR PATENT

Applicant asserts small entity status. See 37 CFR 1.27.

Applicant certifies micro entity sta tus. See 37 CFR 1.29.

Applicant must attach form PTO/SB/15A or B or equivalent.

A check or money order ma de paya ble to the Director of the United State s Patent

and Trademark Office is enclosed to cov er the filing fee and a pplication size fee ( if applica ble). TO TAL FEE AMOUNT ($)

Payme nt by credit card. Fo rm PTO-2038 is attached.

The Director is hereby authorized to charge the filing fee and application size fee (if applicable) or credit any overpayment to De posit

Account Number: __________________.

USE ONLY FOR FILING A PROVISIONAL APPLICATION FOR PATENT

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 10 hours 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.