Fillable System Verification Patent Electronic Form USPTO Use Only (USPTO)

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System Verification Patent Electronic Form USPTO Use Only (USPTO)

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PTO‐2042a (01‐2019)
Approved for use through 06/30/2021. OMB 0651‐0045
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE Under the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control number.
Patent Electronic
Address to:
USPTO Use Only
System Verification
Mail Stop EBC
Commissioner for Patents
Form
P.O. Box 1450
Alexandria, VA 22313‐1450
Block 1 ‐ Requestor Status
Please refer to form fill instructions to minimize processing delays
(select one)
Practitioner Registration Number or Limited Practitioners ONLY
☐
Recognition Number:
Check box to indicate that additional
Registered Practitioner
customer numbers are listed on an
Limited Recognition Practitioner ☐
attached sheet ☐
Se Inve r ☐Pro nto
Customer Numbers – Enter in Space(s) Provided Below
A customer number is an application electronic tracking number assigned by the USPTO that associates your Patent Electronic System
account with one or more patent applications. Please see the instructions if you don't already have a customer number.
Customer Number Customer Number Customer Number Customer Number Customer Number Customer Number
Block 2 ‐ Requestor Information (All Information Required)
First (Given) Name Middle Name Last (Family) Name
Street Address (line 1)
Street Address (line 2)
City State Zip Country
Telephone Number
□ home U TO.gov
(select phone location
SP
)
□ work
Email
□ cell
Address
Block 3 ‐ Type of Action Requested (Must Select at Least One)
☐
Request a new Patent Electronic System account
☐
Update Patent Electronic System account
‐‐ USPTO.gov email address has been changed
Previous email address:
☐
This is a name change.
For registered practitioners or practitioners granted limited recognition, the name provided must correspond to Office of
Enrollment and Discipline records. Please enter the name under which the Patent Electronic System account was previously created
below, and enter new name in space provided in Block 2:
Previous Name:
☐
Associate current Patent Electronic System account with the customer numbers detailed in Block 1
☐
Revoke current Patent Electronic System account
☐
Other – Describe in Detail:
Block 4 – Signature (Required)
I have read and understand the Subscriber Agreement (as listed on www.uspto.gov/ebc) and my signature on this document, by hand, is my
agreement to abide by the Agreement and the rules and policies of the USPTO regarding the Agreement.
I certify that the information, statements and representations provided by me on this form are true and accurate to the best of my
knowledge. I understand that a willfully false certification is a criminal offense and is punishable by law (18 U.S.C. 1001).
Signature Required (Requestor from Block 2)
Date (mm/dd/yyyy)
Patent Electronic
Address to:
USPTO Use Only
System Verification
Mail Stop EBC
Commissioner for Patents
Form
P.O. Box 1450
Alexandria, VA 22313‐1450
Block 5 – Identification (Required)
Notary Seal
SUBSCRIBED and SWORN to before me by (requestor from Block 2)
this day of (month), 20_ , in the county of
in the State of .
Notary Public (signature)
MY COMMISSION EXPIRES:
This collection of information is required under 35 U.S.C. § 2 and § 122. This information is provided by the public as part of the request for or
revocation of a U.S. Patent and Trademark Office (USPTO) Patent Electronic System account. The USPTO will use this information in the process
of issuing or revoking a Patent Electronic System account. The information on this form will be treated confidentially
to the extent allowed under the Government Paperwork Elimination Act, Freedom of Information Act
(FOIA), and the Privacy Act. In order to access information that is released through encrypted communication, you must supply the requested
information in order for the USPTO to issue the necessary digital identity and encryption services.
This form is estimated to take 30 minutes to read the instructions, gather the necessary information, complete the form, read and sign the
subscriber’s agreement, and submit the form to the USPTO. Any comments on the amount of time you require to complete this form and/or
suggestions for reducing this burden should be sent to the Chief Information Officer, U.S. Patent and Trademark Office, U.S. Department of
Commerce, P.O. Box 1450, Alexandria, VA 22313‐1450. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. SEND TO: Mail Stop EBC,
Commissioner for Patents, P.O. Box 1450, Alexandria, VA 22313‐1450.
Privacy Act Statement
This information is collected under the authority of 35 USC 2 and 122. This information is also being collected in conjunction with the provisions
of the Government Paperwork Elimination Act. This information will only be used by the
U.S. Patent and Trademark Office (USPTO) staff to issue and revoke Patent Electronic System accounts. It is requested that you supply this
information so that the USPTO can authorize the creation of a Patent Electronic System account. Furnishing the information on this form
is voluntary, but failure to do so may result in disapproval of this request. The information provided by
you in this form will be subject to the following routine uses:
1.
This information may be disclosed to Federal, state, local, or foreign agencies responsible for investigating, prosecuting, enforcing, or
implementing laws, contracts, rules, or regulations, if these records indicate a violation or a potential violation of a law or contract.
These violations or potential violations can be civil, criminal, or regulatory in nature and can arise from general or particular program
statutes or contracts, rules, regulations, or from the necessity of protecting an interest of the Department.
2.
A record from this system of records may be disclosed to a Federal, state or local agency maintaining civil, criminal or other relevant
enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a
Department decision concerning the assignment, hiring or retention of an individual, the issuance of a security clearance, the letting
of a contract, or the issuance of a license, grant or other benefit.
3.
A record from this system of records may be disclosed in the course of presenting evidence to a court, magistrate, or administrative
tribunal, including disclosures to opposing counsel in the course of settlement negotiations.
4.
A record in this system of records may be disclosed to a member of Congress or to a congressional staff member in response to an
inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained.
5.
A record in this system of records may be disclosed to the Department of Justice to determine whether disclosure is required by the
Freedom of Information Act (FOIA).
6.
The information may be disclosed to the agency contractors who have been engaged by the agency to assist in the performance of a
service related to this system of records and who have need to have access to the records in order to perform the activity.
Recipients of information shall be required to comply with the requirements of the Privacy Act of 1974, as amended, pursuant to 5
USC 552a(m).
7.
The information may be disclosed to the Office of Personnel Management (OPM) for personnel research purposes as a data source
for management information, for the production of summary descriptive statistics and analytical studies in support of the function
for which the records are collected and maintained, or for related man‐power studies.
8.
Records from this system of records may be disclosed to the National Archives and Records Administration or to the General
Services Administration for records management inspections conducted under 44 USC §§ 2904 and 2906.
9.
A record from this system of records may be disclosed, as a routine use, to a Federal, state, local, or international agency, in
response to its request, in connection with the assignment, hiring or retention of an individual, the issuance of a security clearance,
the reporting of an investigation of an individual, the letting of a contract, or the issuance of a license, grant, or other benefit by the
requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter.
pg. 3
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System Verification Patent Electronic Form USPTO Use Only (USPTO)

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Completed 14 June 2021

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