MPEP § fp14.23
The terminal disclaimer filed on [1] disclaiming the terminal portion of any patent granted on this application which would extend beyond the expiration date of [2] has been reviewed and is accepted. The terminal disclaimer has been recorded.
1. In bracket 1, insert the date the terminal disclaimer was filed.
2. In bracket 2, list the Patent Number and/or Application Number (including series code and serial no.). Where an Application Number is listed, it must be preceded by the phrase --any patent granted on Application Number--.
3. See MPEP § 1490 for discussion of requirements for a proper terminal disclaimer.
4. Use form paragraph 14.23.01 for reexamination proceedings.
5. For improper terminal disclaimers, see form paragraphs 14.24 et seq.