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Declaration By Inventor
DECLARATION BY INVENTOR
I, [Name of inventor], am a citizen of [Place of Citizenship of inventor] and believe that I am the original inventor of the invention described in letters patent number [Patent number]. I therefore seek a reissue patent for that invention.
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.
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 my part.:
[List of specific errors]
[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 inventor: [Name of inventor]
Address: [Full name of inventor]
Signature Date