REQUEST FOR REFUND Reference # (Patent #, Application #, Trademark Serial #, Registration #, etc.) Title of Invention or Mark I nformation Attorney Docket # if applicable Payment Date (mm/dd/yyyy) Refund Request Amount Refund Option Select one Reason for Refund Request Refund requests must generally be filed within 2 years of payment date (37 CFR 1.26 and 2.209) Rationale Supporting documentation may be submitted with this form Requester222s Information Company or Firm Name if applicable Address Line 1 City State / Region Address Line 2 (if applicable) Country Zip/Postal Code Email Address You will receive an acknowledgment of receipt only if you provide a valid email address Phone Number Requester222s Name Registration Number if applicable Signature Date (mm/dd/yyyy) Submit online: (registered users only; select "Request for Refund" from the document description menu) Fax to: Mail to: American LegalNet, Inc. www.FormsWorkFlow.com