1. The patentee of Patent No. _______________________, granted on _______________________ for an invention entitled __________________
has, by mistake, accident or inadvertence, and without any wilful intent to defraud or mislead the public,
(a) made the specification too broad, claiming more than that of which the patentee or the person through whom the patentee claims was the (first) inventor; or
(b) in the specification, claimed that the patentee or the person through whom the patentee claims was the (first) inventor of any material or substantial part of the invention patented of which the patentee was not the (first) inventor, and to which the patentee had no lawful right.
2. The name and complete address of the patentee is ___________________
3. (1) The patentee disclaims the entirety of claim _______________________.
(2) The patentee disclaims the entirety of claim ________________________
with the exception of the following: ___________________________________
In section 1, the word "first" may be included only for patents issued on the basis of an application filed before October 1, 1989.
In section 2, the name and address must be presented in the following order with a clearly visible separation between the various elements: family name (in capital letters), given name(s), initials, street name and number, city, province or state, postal code, telephone number, fax number and country.
With respect to each claim covered by the disclaimer, the patentee shall include in the disclaimer either subsection 3(1) or (2).