This form contains 8 fields organized into 3 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Declaration Direction
The attached application	Checkbox	Check this box if this declaration pertains to the application being submitted concurrently or physically attached.
United States application or PCT international application number	Checkbox	Check this box if this declaration pertains to a previously filed United States application or PCT international application, which you will identify by its number.
Application Number	Text	Please provide the United States application or PCT international application number. Fill only if 'United States application or PCT international application number' is 'Yes'. Depends on: United States application or PCT international application number
Filing Date	Date	Please provide the date the application was filed. Fill only if 'United States application or PCT international application number' is 'Yes'. Depends on: United States application or PCT international application number
Title of Invention
Title of Invention	Text	Provide the full title of the invention.
WARNING:
Inventor Name	Text	Provide the full legal name of the inventor.
Date Signed	Date	Provide the date when the inventor signed this declaration. Fill only if 'Inventor Signature' is filled. Depends on: Inventor Signature
Inventor Signature	Text	Provide the signature of the inventor. Fill only if 'Inventor Name' is filled. Depends on: Inventor Name

Form PTO/AIA/01, Declaration (37 CFR 1.63) for Utility or Design Application Using an Application Data Sheet (37 CFR 1.76) Instructions