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Declaration--Design Patent Application
DECLARATION-DESIGN PATENT 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 I am the original inventor of the design entitled [Name of Invention] which I have described and claimed in the attached specification. To the best of my knowledge and belief, this design was never known or used in the United States prior to my invention of it. Nor was it ever patented or offered for public sale prior to that time. I recognize that I have a duty to disclose material information pertaining to this application of which I am aware.
To the best of my knowledge and belief, all the statements made herein are true and were made with the knowledge that willful false statements are unlawful and are punishable by fine or imprisonment, or both.
Signature Date