(a) A declaration of inventorship, referred to in Rule 4.17(iv), that is made for the purposes of the designation of the United States of America shall be worded as follows:
I hereby declare that I believe I am the original inventor or an original joint inventor of a claimed invention in the application.
This declaration is directed to the international application of which it forms a part (if filing declaration with application).
This declaration is directed to international application No. PCT/… (if furnishing declaration pursuant to Rule 26ter).
I hereby declare that the above-identified international application was made or authorized to be made by me.
I hereby acknowledge that any willful false statement made in this declaration is punishable under 18 U.S.C. 1001 by fine or imprisonment of not more than five (5) years, or both.
Residence: … (city and either US state, if applicable, or country)
Mailing Address: …
Inventor’s Signature: … (The signature must be that of the inventor, not that of the agent)
(b) Where there is more than one inventor and all inventors do not sign the same declaration referred to in paragraph (a), each declaration shall indicate the names of all the inventors.
(c) Any correction or addition under Rule 26ter.1 of a declaration referred to in paragraph (a) shall take the form of a declaration referred to in that paragraph and be signed by the inventor. In addition, any such correction should be entitled "Supplemental declaration of inventorship (Rules 4.17(iv) and 51bis.1(a)(iv))".