DISCLAIMER GENERAL FORM IN THE UNITED STATES PATENT AND TRADEMARK OFFICE In re patent of: _____________________________________________ (Name) Patent No.: ______________________ Issued on: _______________________ (Date) For: ____________________________________________________________ (Item) To the Commissioner of Patents and Trademarks: I, __________________________________ (Name and Address of Petitioner), represent that I am _____________________________ (State the Exact Interest of the Disclaimant/Petitioner Here, i.e., Assignee) of the United States letters patent No. ______________ which was granted to ____________________________________ (Inventor) on ________________________ (Date) for _________________________ (Specify Invention) and that I have reason to believe that, without any deceptive intention, the claim of this letters patent is too broad or invalid. Therefore, I disclaim claim ____________________ of such patent. Full Name: ____________________________________________________________ Address: ______________________________________________________________ ___________________________________ ___________________ Signature Date