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Doc Code: PTO/SB/97 (07-09) Approved for use through 07/31/2012. OMB 0651-0031 U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE Under the Paperwork Reduction Act of 1995, no persons
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Name ___ Address C/o [Name] Docket No. I hereby certify that the statements in this communication are true and correct to the best of the individual's knowledge and belief. The individual certifies that the contents of this communication are not confidential and, therefore, neither the content nor the form of the communication shall be withheld from the individual or from others who are lawfully entitled to receive it. Copies of this communication may be reproduced, stored in a retrieval system for later retrieval, or otherwise disseminated without compensation, and in whole or in part, by electronic or mechanical means, including photocopy or recording. The document is not to be forwarded to any Government or departmental agency without written acknowledgment on a part or whole form from the individual. Dated at [Printed Name] U.S. Secret Service U.S.

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