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Declaration--Loss Of Letters Patent
DECLARATION--LOSS OF LETTERS PATENT
I, [Name of Inventor], declare that letters patent No. [Number of patent], which was granted to me on [Date], has either been lost or destroyed. I have made a diligent search for the letters patent everywhere it would probably be found, if it existed, and I have not been able to find it.
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.
Full name of inventor: [Name of Inventor]
Citizenship: [Citizenship of Inventor]
Residence: [Residence of Inventor]
Post Office Address: [Post office address of Inventor]
Signature Date