Name, complete mailing address and telephone number of the
person and company paying the fee:
Patent application or patent #
Reference #
Anniversary
Maintenance fee ($)
Small entity
Reinstatement fee ($)
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
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 or implicitly requested, the Commissioner
is authorized to charge the amount of the deficiency to the deposit account or credit
card identified above.
