Acceptance For Value

Exempt From Levy

Demand For Lawful Money
12 U.S. Code 411
Pay To: The United States Treasury
nd charge the same to: FIRST MIDDLE LAST
Given for patent right *E12345678*
Done in Good Faith *XXXXXXXXX*

Authorized Signature for Represented Person

By: :John-Henry:Doe.
 Acceptance For Value
Exempt From Levy
Demand For Lawful Money
12 U.S. Code 411
Pay To: The United States Treasury
and charge the same to: FIRST MIDDLE LAST
Given for patent right *E12345678*
Done in Good Faith *XXXXXXXXX*

Authorized Signature for Represented Person

By: :John-Henry:Doe.