Serial or Patent No.: Attorney’s Docket No.:                                                  

Filed or Issued: [                    ]  

For:                                                                                                                 

VERIFIED STATEMENT (DECLARATION) CLAIMING SMALL ENTITY

STATUS (37 CFR 1.9 (f) and 1.27 (b)) - INDEPENDENT INVENTOR

As a below named inventor, I hereby declare that I qualify as an independent inventor as defined in 37 CFR 1.9 (c) for purposes of paying reduced fees under section 41 (a) and (b) of Title 35, United States Code, to the Patent and Trademark Office with regard to the invention entitled described in

the specification filed herewith

application serial no. [                      ]                     , filed [                          ]  

patent no. [                     ]   , issued [                       ]  

I have not assigned, granted, conveyed or licensed and am under no obligation under contract or law to assign, grant,

convey or license, any rights in the invention to any person who could not be classified as an independent inventor

under 37 CFR 1.9 (c) if that person had made the invention, or to any concern which would not qualify as a small

business concern under 37 CFR 1.9 (d) or a nonprofit organization under 37 CFR 1.9 (e).

Each person, concern or organization to which I have assigned, granted, conveyed, or licensed or am under an

obligation under contract or law to assign, grant, convey, or license any rights in the invention is listed below:

no such person, concern, or organization

persons, concerns or organizations listed below*

*NOTE: Separate verified statements are required from each named person, concern or organization

having rights to the invention averring to their status as small entities. (37 CFR 1.27)

FULL NAME

ADDRESS

[  ]  INDIVIDUAL                    [   ]  SMALL BUSINESS CONCERN                        [   ]  NONPROFIT ORGANIZATION

FULL NAME

ADDRESS

[  ]  INDIVIDUAL                    [   ]  SMALL BUSINESS CONCERN                        [   ]  NONPROFIT ORGANIZATION

FULL NAME

ADDRESS

[  ]  INDIVIDUAL                    [   ]  SMALL BUSINESS CONCERN                        [   ]  NONPROFIT ORGANIZATION

I acknowledge the duty to file, in this application or patent, notification of any change in status resulting in loss of entitlement to small entity status prior to paying, or at the time of paying, the earliest of the issue fee or any maintenance fee due after the date on which status as a small entity is no longer appropriate. (37 CFR 1.28 (b))

I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and belief are believed to be true; and further that these statements were made with the knowledge that willful false statements and the like so made are punishable by fine or imprisonment, or both, under section 1001 of Title 18 of the United States Code, and that such willful false statements may jeopardize the validity of the application, any patent issuing thereon, or any patent to which this verified statement is directed.

NAME OF INVENTOR             NAME OF INVENTOR             NAME OF INVENTOR

Signature of Inventor           Signature of Inventor             Signature of Inventor

         Date                                    Date                                 Date