Privacy Notice
All personal information created, held or collected by the Canadian Intellectual Property Office is protected under the Privacy Act. This means that you will be informed of the purpose for which it is being collected and how to exercise your right of access to that information. You will be asked for your consent where appropriate.
Date:
Listing #
Name, complete mailing address and telephone number of the person and company paying the fee:
| Patent application or patent # | Reference # | Anniversary | Maintenance fee ($) | Small entity | Reinstatement fee ($) | Late fee ($) | Total |
|---|---|---|---|---|---|---|---|
|
Please note that if the amount paid is less than the amount of the fees identified on the form, the Office will apply the amount paid to as many of the fees identified on the form as possible beginning at the top of the list. |
Page Total | ||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
___ Additional sheets attached for listing additional patent applications or patents
The applicant requests reinstatement of the application in respect of each failure to pay a maintenance fee for which a reinstatement fee is paid.
For Canadian Intellectual Property Office use only
Method of Payment
Please note that we only accept Canadian currency.
- ___ Cash
- ___ Cheque
- ___ Bank draft
- ___ Credit card
- ___ Postal money order
- ___ Bank transfer
- ___ Other (specify):
______________________
- ___ Deposit account
Authorization to charge deposit account or credit card
(By paying with a credit card or by deposit account, you are hereby authorizing CIPO to charge the total fees indicated above.)
Credit card
- Credit card No.: __________________
- Expiration date: __________________
- Signature: ______________________
Deposit account
- Deposit account No.: ______________
- Name: _________________________
- Signature: ______________________
Should the fees submitted with this maintenance fee calculation sheet be insufficient to cover all of the fees for which payment is explicitly requested and if clear authorization statement to charge a deficiency was included, the Commissioner, upon evaluation of that statement, may charge the amount of the deficiency to the deposit account or credit card identified above.