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Disclaimer General Form
DISCLAIMER GENERAL FORM
IN THE UNITED STATES PATENT AND TRADEMARK OFFICE
In re patent of: [Name of applicant]
Patent No.[patent number]
Issued on: [date]
For: [Item]
To the Honorable Commissioner of Patents and Trademarks:
I, [Name and Address of Petitioner], represent that I am [State the Exact Interest of the Disclaimant/Petitioner Here, i.e., Assignee] of the United States letters patent No. which was granted to [Name] on [Date] for [Description of Invention] and that I have reason to believe that, without any deceptive intention, the claim of this letters patent is too broad or invalid. Therefore, I disclaim claim of such patent.
Name: [Name of applicant]
Address: [Address of applicant]
Signature Date