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Deposit Ticket Declaration Form
For use with applications and physical deposits SUBMITTED ON OR AFTER April 2, 2020.
Please complete this declaration form and upload it along with your electronic deposit copy.
Under penalty of perjury under the laws of the United States of America,
The undersigned, as the applicant or the applicant’s duly authorized agent or representative, hereby declares that the work
I am registering, titled
is subject to the “best edition” requirement and I have sent or will send within three business days the required number
of physical copies of the “best edition” of this work to the U.S. Copyright Oce as required by 17 U.S.C. § 408(b) and all
applicable U.S. Copyright Oce regulations.
Further, I declare that the electronic copy I will upload via the electronic registration system is a complete, true and accurate
copy of the work I intend to register, and the content of the electronic copy is identical to the content of the physical “best
edition” copies that I have sent or will send within three business days to the Oce.
I acknowledge that any person who knowingly makes a false representation of a material fact in the application for
copyright registration provided for by 17 U.S.C. § 409, or in any written statement led in connection with the application,
is subject to criminal penalties under 18 U.S.C. § 1001(a)(2).
Printed Name: Date:
deposit ticket declaration form [submitted on or after] united states copyright office
