ࡱ> 685%` bjbj"x"x 1"@@R <<<P ,PK $!h<w "  8 < $< U @&0K'''<$ Z @3 4g /  KPPPd PPP PPP  ĢƵ, ĢƵ DECLARATION OF INSTITUTIONAL SUPPORT (Inventions) 1. Name of Inventor(s): 2. Title of Invention: 3. Inventor(s) Declaration: An invention is considered to have partial institutional support if the institution incurs resource costs associated with the invention. Institutional support includes those costs which would not have been incurred by the institution in the absence of the development of the invention or discovery, as well as those other costs associated with the significant use of University / SJSU Foundation equipment, supplies, facilities, employee time, or other institutional resources. I (we) declare that the following institutional resources were used in association with the development of my (our) invention: (If none, so indicate: if not applicable, write N/A.)  Specifically acquired for invention: Facilities (acquired solely or partially for invention): Other institutional resources: TOTAL DIRECT COSTS $ ______________ Indirect Costs: Estimate of space / utilities: Other indirect costs: TOTAL INDIRECT COSTS $ ______________ TOTAL COSTS INCURRED BY INSTITUTION $ ______________ *Indicate the source of funds (State, Foundation, other). Signature of Inventor(s): ________________________________________________ Date: ___________________________ ________________________________________________ Date: ___________________________ ________________________________________________ Date: ___________________________ 5. Department Chair: (type name) _____________________________________________________________ _________ I concur with the foregoing declaration of institutional resource costs associated with the above titled invention. _________ I do not concur with the foregoing estimate of institutional resource costs associated with the above titled invention. An amended statement of institutional resource costs associated with the above titled invention is attached. Chairs Signature: ____________________________________ Date: ____________________________ 6. College Dean: (type name) _________________________________________________________________ _________ I concur with the foregoing declaration of institutional resource costs associated with the above titled invention. _________ I do not concur with the foregoing estimate of institutional resource costs associated with the above titled invention. An amended statement of institutional resource costs associated with the above titled invention is attached. Deans Signature: _____________________________________ Date: ____________________________ CategoryPersonnel / Services:  Description Dates Used  Amount of Support Received* Supplies: Equipment: Existing:  23YfgiJ K L < R8@QSŹwwhw]W hCJh6CJ]aJh6B*CJ]aJphhB*CJaJphhCJaJhB*phjhUmHnHuhB*CJaJphhB*CJaJphhB*CJaJphh5B*CJ\aJph#h56B*CJ\]aJphh5B*CJ\aJph h+]56h2gJ L u $ < s$d/+4&a$$di2) &a$|d%$&`| $"@ &a$ $j&a$ $Q &a$ d3 $& $k&a$$d/ &a$$/ &1$a$gd+] R D R$Rv %& d/$& d$& d '& k&& d 6#& di<#& $m#& 9Y!& $7T$&a$ $R5T$&a$$dYG1&a$ RSrSkd$$Ifl\ in$ , 04 la $$Ifa$$If1$7$8$H$ d[ $$Ifa$kd$$Ifl\ in$ , 04 la$IfWQOF %&$Ifkd$$Iflr< in$R, 04 la/0P/ ?!"#z$% $$If!vh5 55,5 #v #v#v,#v :V l0,5 55,5 4$$If!vh5 55,5 #v #v#v,#v :V l0,5 55,5 4$$If!vh55S55,5 #v#vS#v#v,#v :V l0,55R55,5 4<`< +]NormalCJ_HmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List XOX Default1$7$8$H$!B*CJ_HaJmH phsH tH ,O, CM4 B*ph,O, CM5 B*ph2O2 CM1d B*ph,O, CM2 B*ph2O2 CM3d B*ph  "2gJLu$<DR$ R S r 0@000000000000000000000000X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 X00 0X00  R  8@6(    C F.`T`T`T`T3" B S  ?J -@ntn*n''n