INVENTION DISCLOSURE FORM

The purpose of this form is to obtain a description of your invention to assist in the patent process. Please answer the following questions as well as possible. Attach additional sheet(s) if needed. (The spaces will expand automatically for electronic users). (For help, please consult the Example Completed Invention Disclosure on www.epri.com .)

Work ID: / Project ID:
Date of Submission to IP Dept.
EPRI
Project Manager: / Sector:

1. TITLE: Provide a title that is descriptive of your invention.

2. IDENTIFICATION OF INVENTOR(S): Identify the key inventor to whom questions can be directed. For each inventor, provide the following:

A. (Key) Full legal name
Employer
Residence Address
Citizenship
Work Phone Number
Work email
B. Full legal name
Employer
Residence Address
Citizenship
Work Phone Number
Work email
C. Full legal name
Employer
Residence Address
Citizenship
Work Phone Number
Work email
D. Full legal name
Employer
Residence Address
Citizenship
Work Phone Number
Work email

(FOR ADDITIONAL INVENTORS, PLEASE ATTACH SHEET)

3. RELATION OF THE INVENTION TO EPRI: Provide the identity of any EPRI program names, Contracts or Agreements to this invention. Provide a copy of the contract or agreements when submitting the disclosure (or a contract number). (If the contract states someone other than EPRI will hold title of the patent, also provide name of entity.)

Please check if developed under: /_/ University Contract or /_/ Government Agreement.

4. DESCRIPTION OF THE INVENTION

A. PROBLEM ADDRESSED BY THE INVENTION: Describe the problem or need addressed by your invention. What problem does your invention solve, or what need does your invention fulfill?

B. STATE OF THE ART: Identify any relevant literature or patents of which you are aware and a short description (including any EPRI reports or other prior written descriptions of the invention, any prior art patents or publications, and any presentations). Describe how this problem or need has been addressed in the past.

C. DETAILED DESCRIPTION: Provide a detailed description of what your invention is and how it works. What are the components (or steps if the invention is a method) of the invention and what is the function of each component? How do the components interact with each other? What are the novel aspects of your invention? Include sketches, drawings, photographs, etc. to help illustrate your invention. (Drawings may be attached on a separate sheet or included in the detailed description.)

D. RESULTS AND ADVANTAGES: What are the results and advantages of using your invention? How does it work differently from other devices or processes that accomplish the same purpose?

E. ALTERNATIVES: Are there any variations of your basic invention that accomplish the same purpose?

5. SIGNIFICANT DATES: When did you first think of the idea for your invention? Do you have any documentation of that date? If so, please identify.

A. Conception of the Invention
1. Documentation (of the date of conception):
B. When the invention was first reduced to practice

6. USE AND DISCLOSURE (IMPORTANT): Please answer the following questions:

A.  Have you described or shown your invention to anyone? / YES ( ) / NO ( )
B.  Have you made any attempts to commercialize your invention (for example, have you approached any companies about purchasing or manufacturing your invention)? / YES ( ) / NO ( )
C.  Has your invention been described in any printed publication, or any other form of media, such as the Internet? / YES ( ) / NO ( )
D.  Have you used, or do you plan to use, the invention in commerce?
/ YES ( ) / NO ( )
E.  Have you attempted to manufacture or sell your invention, or offered it for sale? / YES ( ) / NO ( )
F.  Have you conducted any prior art searches? / YES ( ) / NO ( )

If you have answered yes to any of the above questions, please give full details of the activity, including dates when activities have occurred. Please indicate if party(ies) where under obligation of confidentiality.

7. FILING OPTIONS: Please indicate any foreign countries within which you would suggest that the application should be filed. Please refer to the attached ESTIMATES by country before entering this information.

8. Provide names of possible licensees, if any.

Before submitting to the Patent Department, please have your manager review and sign this invention disclosure.

Signature EPRI Inventor or Project Manager / Typed Name of Inventor / Date
Signature of Inventor’s Sector Manager / Typed Name of Sector Manager / Date
Estimated Cost Per Patent Application
in the United States and
in the most common Foreign Countries
Description of Cost: / Outside Counsel Fee
(Rough Estimate) / Out of Pocket Costs During Pendency / Estimated Lifetime Annuities / Low End Estimate / High End Estimate
Total for U.S. Only / $10,900 / $29,000 / $3,390 / $ 8,710 / $ 23,000 / $41,100
Foreign Filing / Assoc. Fee Low / Assoc. Fee High / Min. U.S. Outside Counsel Flat Fee / Lifetime Annuities / Low End Estimate / High End Estimate
Australia / $3,000 / $5,000 / $1,250 / $12,000 / $ 16,250 / $18,250
Canada / $3,000 / $5,000 / $1,250 / $13,000 / $ 17,250 / $19,250
China / $3,000 / $5,000 / $1,250 / $30,000 / $ 34,250 / $36,250
EPO (UK, DE, FR) / $10,000 / $20,000 / $1,250 / $22,000 / $ 33,250 / $43,250
Japan / $7,000 / $16,000 / $1,250 / $41,000 / $ 49,250 / $58,250
Korea / $4,000 / $10,000 / $1,250 / $36,000 / $ 41,250 / $47,250
Russia / $5,000 / $12,000 / $1,250 / $27,000 / $ 33,250 / $40,250
South Africa / $2,500 / $5,000 / $1,250 / $12,000 / $ 15,750 / $18,250
Total for Foreign Filing / $240,500 / $281,000
Total per family: / $263,500 / $322,100

September 2012 Invention Disclosure Form Page 6

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