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SAMPLE FORM

PATENT RECORDATION FORM
COVER SHEET

Attorney Docket No. 22 ¹

To the Commissioner for Patents: Please record the attached original document or copy thereof.

1. Name of conveying party(ies):

(1) Anne Lieber ²
Name of Party Assigning Rights

(2) John Moser ³
Name of Party Assigning Rights

Additional name(s) of conveying party(ies) attached?

[ ] Yes [ x] No⁴

2. Name and address of receiving party(ies):

Name: Louis ⁵ Name of Receiving Party(ies)

Internal Address: ⁶

⁶

_525E_________________⁶

3. Nature of Conveyance:⁹

[ ] Assignment [ x] Merger [ ] Security Agreement

[ ] Change of Name [ ] Other

_________________________________________
If other, Explain

Execution Date: June 21, 1995¹⁰
List Date(s) Document Executed

Street Address: 1450 60th St. NW ⁷

___________________________________

City New York State NY ZIp 10004 ⁷

Additional name(s) & address(es) attached? [ ] Yes [ x] No⁸

4A. Application No.(s)

002 & 045¹¹
Serial No.(s) - if Applicable

If this document is being filed together with a new application, the execution date(s) of the application is:

_______________________________________¹²Execution Date(s) of Appln. - If applicable

Additional numbers attached? [ x] Yes [ ] No¹³

4B. Patent No.(s)¹⁴

__________________2_____________¹⁴ Patent No.(s) - if Applicable

Additional numbers attached? [ ] Yes [ x] No¹⁵

5. Name and address of party to whom correspondence concerning document should be mailed:

6. Total number of applications and patents

involved: [ 3]¹⁸

Name: Carlos Menz¹⁶

Responsible attorney

7. Total fee (37 CFR 3.41):.....$ 50⁰⁰ ¹⁹

Street Address: 5040 30th St. SE ¹⁷

_____________________________________

City: New York State: NY ZIP 10004¹⁷

8. Method of Payment

[ x] Enclosed

[ ] The Commissioner is authorized to charge payment of any additional recording fees or credit any overpayment to deposit account No. ______________.

DO NOT USE THIS SPACE

9. Statement and signature.

To the best of my knowledge and belief, the foregoing information is true and correct and any attached copy is a true copy of the original document.

Anne Lieber ²¹

Name of Person Signing

Anne Lieber ²² May 31, 1995 ²³
Signature Date

Total number of pages including cover sheet, attachments and document: [ 5 ]²⁴

This is not a substitute for legal advice. An attorney must be consulted.
Copyright ©1994 - 2024 by LAWCHEK, LTD.

The above is an example of how a typical Patent Recordation form may be completed.

1. This number is assigned by the attorney’s office.

2. The full name of the party assigning rights.

3. The full name of the party assigning rights-- if needed.

4. Indicate whether or not there are additional names of persons assigning rights.

5. The full name of the receiving party(ies).

6. In case of a large company, the company name would be provided here.

7. The full address of the receiving party(ies).

8. Indicate whether or not there are additional names of persons receiving rights.

9. Indicate the reason for the conveyance.

10. The date on which the document takes effect.

11. The numbers of the application(s).

12. The execution date(s) of additional applications.

13. Indicate whether or not there are additional application numbers attached.

14. Provide the number(s) of the patent(s) involved in this conveyance.

15. Indicate whether or not there are additional patent numbers attached.

16. The full name of the attorney handling this document.

17. The full address of the attorney.

18. The number of patents and applications involved in this conveyance.

19. The fee for processing.

20. Check the method of payment that applies.

21. The printed name of the person signing.

22. The signature of the person signing.

23. The date on which the document is signed.

24. The total number of pages included in this patent record.

This is not a substitute for legal advice. An attorney must be consulted.