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Declaration By Sole Inventor--To Accompany Application


State of [State]
County of [County]

My name, address, citizenship, and residence are as follows:

Full name of inventor: [Full Name of inventor]
Citizenship: [Citizenship]
Residence: [Residence]

Post Office Address: [Post Office Address]

I believe that I am the original inventor of the invention entitled
[Title of Invention] described in the attached specification.

To the best of my knowledge and belief, this invention was never known or used in the United States prior to my invention of it nor was it ever patented or offered for sale in the United States before my invention of it.

I recognize that I have a duty to disclose any material information of which I am aware.

I hereby declare that all statements herein are true to the best of my knowledge and belief. In this respect, I am aware that it is unlawful to willfully make false statements in connection with an application or any patent issued thereon

Signature Date