Doc Code: WFEE Document Description: Fee Worksheet (PTO-875) PTO/SB/06 (09-16) Approved for use through 09/30/2016. OMB 0651-0031 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 APPLICATION FEE DETERMINATION RECORD Substitute for Form PTO-875 Application or Docket Number LARGE ENTITY MICRO ENTITY SMALL ENTITY RATE ($) N/A N/A N/A x x = = APPLICATION AS FILED ­ PART I (Column 1) NUMBER FILED N/A N/A N/A minus 20 = minus 3 = * * FOR BASIC FEE (37 CFR 1.16(a), (b), or (c)) SEARCH FEE (37 CFR 1.16(k), (i), or (m)) EXAMINATION FEE (37 CFR 1.16(o), (p), or (q)) TOTAL CLAIMS (37 CFR 1.16(i)) INDEPENDENT CLAIMS (37 CFR 1.16(h)) APPLICATION SIZE FEE (37 CFR 1.16(s)) (Column 2) NUMBER EXTRA N/A N/A N/A FEE ($) If the specification and drawings exceed 100 sheets of paper, the application size fee due is $400 ($200 for small entity or $100 for micro entity) for each additional 50 sheets or fraction thereof. See 35 U.S.C. 41(a)(1)(G) and 37 CFR 1.16(s). MULTIPLE DEPENDENT CLAIM PRESENT (37 CFR 1.16(j)) * If the difference in column 1 is less than zero, enter "0" in column 2. N/A TOTAL APPLICATION AS AMENDED ­ PART II (Column 1) CLAIMS REMAINING AFTER AMENDMENT TOTAL (37 CFR 1.16(i)) LARGE ENTITY SMALL ENTITY MICRO ENTITY AMENDMENT A (Column 2) HIGHEST NUMBER PREVIOUSLY PAID FOR Minus Minus ** *** (Column 3) PRESENT EXTRA = = x x RATE ($) ADDITIONAL FEE ($) = = * * INDEPENDENT (37 CFR 1.16(h)) APPLICATION SIZE FEE (37 CFR 1.16(s)) FIRST PRESENTATION OF MULTIPLE DEPENDENT CLAIM (37 CFR 1.16(j)) N/A TOTAL ADD'L FEE (Column 1) CLAIMS REMAINING AFTER AMENDMENT TOTAL (37 CFR 1.16(i)) AMENDMENT B (Column 2) HIGHEST NUMBER PREVIOUSLY PAID FOR Minus Minus ** *** = = (Column 3) PRESENT EXTRA x x RATE ($) ADDITIONAL FEE ($) = = * * INDEPENDENT (37 CFR 1.16(h)) APPLICATION SIZE FEE (37 CFR 1.16(s)) FIRST PRESENTATION OF MULTIPLE DEPENDENT CLAIM (37 CFR 1.16(j)) N/A TOTAL ADD'L FEE * If the entry in column 1 is less than the entry in column 2, write "0" in column 3. ** If the "Highest Number Previously Paid For" IN THIS SPACE is less than 20, enter "20". *** If the "Highest Number Previously Paid For" IN THIS SPACE is less than 3, enter "3". The "Highest Number Previously Paid For" (Total or Independent) is the highest number found in the appropriate box in column 1. The information is required by 37 CFR 1.16. Confidentiality is governed by 35 U.S.C. 122 and 37 CFR 1.11 and 1.14. This collection is estimated to take 12 minutes to complete, including gathering, preparing, and submitting the completed application form to the USPTO. Time will vary depending upon the individual case. 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 FEES OR COMPLETED FORMS TO THIS ADDRESS. SEND TO: Commissioner for Patents, P.O. Box 1450, Alexandria, VA 22313-1450. If you need assistance in completing the form, call 1-800-PTO-9199 and select option 2. 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