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MULTIPLE DEPENDENT CLAIM 
FEE CALCULATION SHEET 

(FOR USE WIT^BllM PTO-875) 


rO 7"53 559 


c 


A C IT 

Ao r 

ILfLD 

AFTER 

■ 1* AMENDMENT . 

AFTER 
I "amendment 

INn 


IND. 

DEP. 

IND. 

DEP. 

1 

2 



/ 




4 




/ 



5 




y 



6 




/ 



7 




/ 



8 




/ 



9 




/ 



10 




/ 



11 




/ 



12 




y 



13 







14 




/ 



15 




/ 



16 




/ 



17 




/ 



18 







19 







20 




/ 



21 







22 







23 







24 







25 







26 







27 







28 







29 







30 







31 







32 







33 







34 







35 







36 







37 







38 







39 







40 







41 







42 







43 







44 







45 







46 







47 







48 







49 







50 







TOTAL IND. 



/ 




TOTAL DEP 




TOTAL 
CLAIMS 




mm 




AS F 

ILED 

AF 

fAME 

TER 

NDME3VT 

AFTER 
z "'amendment 



IND. 

DEP. 

IND. 

DEP. 

51 







52 







53 







54 







55 







56 







57 







58 







59 







60 







61 







62 







63 







64 







65 







66 







67 







68 







69 







70 







71 







72 







73 







74 







75 







76 







77 







78 







79 







80 







81 







82 







83 







84 







85 







86 







87 







88 







89 







90 







91 







92 







93 







94 







95 







96 







yl 







98 







99 







100 







TOTAL IND. 







TOTAL DEP 




TOTAL 
CLAIMS 


mm 




mm 


PTO- 1360 (REV. IIA1.I) 


%}S. DEPARTMENT of COMMERCE 
P«C««< and TradcniArk OfTicc