DISCLAIMER PATENT TERM 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) am ______________________________ (State Exact Interest of the Disclaimant Here, I.e. Assignee) of the application filed on __________________________ (Date) for ___________________________________________________ (Specify Invention), No. _____________________. I hereby disclaim all the portion of the term of any patent which may be issued on that application after ______________________ (Date). Name: ________________________________________________________________ Address: ______________________________________________________________ ___________________________________ ___________________ Signature Date