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Declaration By Assignee
DECLARATION BY ASSIGNEE
I, [Name of corporate officer], [Title of corporate officer] of [Name of Corporation], hereby declare that I am a citizen of [Place of Citizenship of corporate officer] and a resident of [Place of Residence of corporate officer]. I also hereby declare that letters patent number which was granted to [Name of Inventor] on [Date granted] is now owned entirely by [Name of Corporation]. I believe [Name of Inventor] is the original inventor of the invention claimed in the above letters patent and for which I seek a reissue patent. To the best of my knowledge and belief, this invention was never known or used in the United States prior to its invention by [Name of Inventor].
The following is a list of the specific errors which were relied upon as well as a description of how they arose. These errors arose without any deceptive intention whatsoever on the part of the applicants.:
[List of specific errors]
[Insert here allegations from the appropriate paragraphs of 37 Code of Federal Regulations section 1.175(a)]
Furthermore, to the best of my knowledge and belief, all statements made herein are true and were made with the knowledge that willful false statements are unlawful and punishable by fine or imprisonment, or both.
Full Name of Assignee:
Name of Officer of Assignee:
Address:
Signature of Officer Date