For IPTL Use Only

Plant Variety Disclosure Form

/ For OTM use only.
Disclosure #:

Instructions: Please complete all applicable sections of the disclosure form and circulate for signatures (including dept heads, deans or directors). The completed form should be forwarded to the Office of Technology Management at Mail Stop 9565. To expedite the review process, please submit an electronic copy by e-mail to . For additional assistance, call 662-325-9263.

Mississippi State University (MSU) Intellectual Property Policy recognizes novel plant cultivars and germplasms as Plant Intellectual Property. The following is a disclosure of a novel plant cultivar or germplasm which reasonably appears to qualify for protection under the plant patent laws or plant variety protection (PVP) laws of the United States, whether or not patentable or protected thereunder, developed by faculty, staff, or students employed by MSU or developed by any person whether or not using facilities of MSU who is required to disclose inventions to MSU.

1. Inventor(s)/Creator(s)

Include the names of any co-inventors (including any non-MSU inventors) in the order they should appear in official documents. A co-inventor is an individual who has conceived or contributed an essential element of the invention, either independently or jointly with others, during the evolution of the technology concept or reduction to practice (may include graduate students).

1.1. A person who merely suggests an idea or a result rather than a means of accomplishing it is not a joint inventor.

1.2. A person who merely carries out experiments planned wholly by another is not a joint inventor.

1.3. A person who does not contribute to the inventive concept(s) is not a joint inventor.

1. Inventor:
Position:
*Dept/Unit:
Mail Stop:
Phone:
E-mail Address:
Home Address:
Country of Citizenship: / 3. Inventor:
Position:
*Dept/Unit:
Mail Stop:
Phone:
E-mail Address:
Home Address:
Country of Citizenship:
2. Inventor:
Position:
*Dept/Unit:
Mail Stop:
Phone:
E-mail Address:
Home Address:
Country of Citizenship: / 4. Inventor:
Position:
*Dept/Unit:
Mail Stop:
Phone:
E-mail Address:
Home Address:
Country of Citizenship:

*If you have a split appointment, list only the Department, Center or Unit(s) that contributed to your support in the development/research of this technology (for use in distributing department/unit share of any future royalties).
2. Plant Variety Type and Name

a. Type of plant/crop proposed for release:

b. Scientific Name:

c. Common Name:

d. Name and Address of facility/facilities where Cultivar/Germplasm was developed:

e. Designation name used for breeding line/strain/variety in experimental and developmental stage:

f. Proposed cultivar name to be used after release:

g. Is crop sexually or asexually produced?

h. Will trademarks be applied for in this variety?

3. Dates of Conception/Breeding History

a. Date variety conceived or generated (conception date):

b. Date of determination:

c. Number of generations/years spent in development:

d. List Linage and original selection number:

4. Publication or Public Disclosure/Use

a. Has information related to the variety been published or disclosed/used? (Note: Publications/disclosures may include: public variety and strain test(s); MAFES bulletins; posters; cooperative trials; trial gardens; abstracts; manuscripts; theses; research reports to funding agencies; seminars; press releases; interviews; etc.).

b. If so, please acknowledge whether the publication or disclosure was oral or written, when the disclosure took place, the author of the publication, and any changes to the variety since public disclosure? (Please attach copies of any publications, and yield trials with dates).

c. Is a publication or oral disclosure descriptive of the variety planned within the next six months? (This includes dissertations and presentations to anyone outside MSU).

d. Has the variety been disclosed to industry representatives?

e. Has the variety been sold or offered for sale?

f. Has application to the MAFES plant materials release committee been made?

g. Please record below all distributions of seed or vegetative stock of the Cultivar/Germplasm that have been made. Indicate the terms under which the distributions were made, i.e. testing,

seed/stock to be samples only, “used for bulking up” or seed increases, used for further

breeding efforts, free to be distributed to third parties, etc. List name, date, address, and terms

of distribution.

5. Description of the Plant Variety

a. Please provide a summary of the unique, novel, superior or differentiating characteristics justifying release.

b. Attach to this form a detailed statement of performance of the proposed cultivar, including statistical comparison with standard cultivars, information needed to establish the cultivar as “unique” or “novel,” and information concerning the development of the cultivar (dates of establishment as “novel” cultivar or actual production, etc.). See Rules and Regulations at http://www.ams.usda.gov/science/PVPO/PVPO_Act/whole2.pdf

c. Were any patented traits, genes, genetic sequences, or methods used in the development of the germplasm proposed for release? If so, please identify the components used.

6. Commercial Potential

a. Has commercial interest been shown in the variety?

b. What is the region of adaptation of the variety?

c. Is this considered to be a replacement cultivar for an existing variety?

d. Please list any companies that have been contacted or should be contacted about licensing and commercializing the variety (include company name and contact information).

e. Please acknowledge the degree of contact with the aforementioned company(s).

1. Was the company(s) contacted about the technology and only provided non-confidential information?

2. Was confidential information regarding the variety disclosed under a Confidentiality Agreement?

3. Was confidential information regarding the variety disclosed without signing a Confidentiality Agreement?

4. Are there other companies that have not been contacted that the inventor believes might be interested?

7. Additional Information

a. Is the recommended procedure for release; unconditional public release, non-exclusive release (license one or more agents), or exclusive release (bid process to identify single agent)? Please review MAFES Policy and Procedures of Release and Distribution of Newly Developed Plant Materials.

b. Should a plant patent application or an application for plant variety protection be filed?

c. Please estimate the likelihood that a similar variety may be developed elsewhere or provide the reason for urgency (sale of variety, etc.).

d. Should a utility patent be filed associated with this plant variety? (Note: Utility patents are issued for an invention of a new and useful process, one or more traits, plant parts, methods of identifying, methods for using plant varieties, or composition of matter and extracts, or a new and useful improvement thereof).

e. Is certification of seed or materials required?

f. Please note the quantity and availability of breeder seed or other plant material as required and who will be responsible for maintaining the seed or plant stock.

g. What is the proposed arrangement for Foundation Stock increase and which party is responsible for distribution of stock?

8. Third Party Rights/Material Transfer Agreement

a. List any person/company you have contacted regarding development and commercializing the Cultivar/Germplasm; also state any commitments made to such person and whether you believe such a commitment, if any, to be legally binding.

b. Have any materials or information been supplied to non-industry contacts (breeders or collaborators at other institutions under terms and conditions of a MSU Material Transfer Agreement or Non-Disclosure Agreement)?

c. Have any materials or confidential information belonging to another institution or company been used in the conception or development of the invention? For example, have donor materials been received from colleagues at MSU or at another institution or have you received a request to sign a Material Transfer Agreement, etc? If so, please include a description of the material or information and the company or university providing the material or information.

d. Has a Material Transfer Agreement, Non-Disclosure Agreement, License, Purchase, or any other Agreement been signed? If so, please list all Agreements that may apply.

9. Funding Information

a. Grants and Contracts. Please note that accurate and complete sponsorship information is necessary to fulfill MSU obligations under research grants and contracts.

Was this invention developed with the use of any research grant/contract funds (include funding from any source in whole or in part)? Yes  No 

If yes, please provide:

Sponsor / Grant/Contract Number / Grant/Contract Dates / Banner Fund Number / Principal Investigator

b. Additional Information for CVM, MAFES, FWRC and MSU-ES. Was this invention developed with the use of any appropriated funds (Banner #s: 160000, 170000 or 180000, etc.)? Yes No 

If yes, please provide:

CRIS Activity Code or MSU-ES Fund # / Dates of Activity / Indicate project designation (Multi-State, AHF, Hatch, McIntire-Stennis, Smith-Lever, Other)

c. Was this invention developed outside the university employment of the inventor(s) with no use of university facilities or equipment? Yes  No 

10. Royalty Sharing/Letter of Agreement.

Royalty licensing income payable to MSU inventors will be distributed among multiple MSU inventors in accordance with the Percent Share shown below (i.e. the distribution payable to an individual MSU inventor will be calculated by multiplying the Percent Share by the total amount payable to all MSU inventors in accordance with the current Policy and Procedure Statement on Intellectual Property at Mississippi State University). Note: Co-inventors from outside MSU will be subject to the royalty sharing of their institution. OTM will contact the other institution and negotiate an agreement for joint-ownership and management of this technology.

Printed/Typed Name:
*MSU ID #:
Percent Share: _____% / Printed/Typed Name:
*MSU ID #:
Percent Share: _____%
Printed/Typed Name:
*MSU ID #:
Percent Share: _____% / Printed/Typed Name:
*MSU ID #:
Percent Share: _____%

*Please note that the MSU ID number is required; absence of this information may hinder distribution of the inventors’ share of any royalties that may result from this technology.

11. Signatures

Title of Invention:

The undersigned Mississippi State University inventor(s) concur with the information contained in this disclosure, and hereby assign and agree to assign all title and rights for the inventions and improvements herein to Mississippi State University and hereby agree to the above Percent Share for any licensing income payable to them.

MSU Inventor(s) / Witness(es):
______
Signature Date
______
Name of Inventor (please type or print) / ______
Signature Date
______
Name and Title of Witness (please type or print)
______
Signature Date
______
Name of Inventor (please type or print) / ______
Signature Date
______
Name and Title of Witness (please type or print)
______
Signature Date
______
Name of Inventor (please type or print) / ______
Signature Date
______
Name and Title of Witness (please type or print)
______
Signature Date
______
Name of Inventor (please type or print) / ______
Signature Date
______
Name and Title of Witness (please type or print)

Approved by:

Signature Date

Print Name (Dept. Head, Dean or Director) /
Signature Date

Print Name (Dept. Head, Dean or Director)

Signature Date

Print Name (Dept. Head, Dean or Director) /
Signature Date

Print Name (Dept. Head, Dean or Director)

Signature Date

Print Name (Dept. Head, Dean or Director) /
Signature Date
Kristin L. McCandless

University Patent Officer

Approved: Royalty Sharing/Letter of Agreement

Signature Date

Print Name (Vice President) /
Signature Date

Print Name (Vice President)

MSU Plant Variety Disclosure Form – v6.7.16 Page 6
Note: The completed disclosure is an internal MSU document. This disclosure or its submission to OTM
does not provide patent protection. Please continue to keep the information in this disclosure confidential.

Plant Variety Disclosure Form – Final Checklist

(For inventors, department heads, directors and deans)

1. Have all potential inventors/creators been listed on the first page(s) of the form? Please note that inventorship differs greatly from authorship. Inventorship is determined by U.S. Patent Law and may apply to anyone who contributed to the conception of the invention as described in the disclosure, including refinements or improvements that were essential to the success of the invention. Any employee (including technicians) or student (graduate or undergraduate) can be an inventor.

2. Have all of the inventors/creators signed the disclosure in blue ink in Section 11 of the form and had their signature witnessed?

3. Have the appropriate department head(s), director(s) and dean(s) also signed the disclosure?

4. Has a funding source(s) been indicated in Section 9? At least one funding source MUST be indicated. If nothing else, the source of funds for the inventor’s salary should be listed. If the research was funded by a federal agency, even if the research is outside the scope of the relevant grant proposal, that federal funding MUST be indicated.

5. Have the relevant MSU Banner account numbers been provided for the funding source(s)?

6. Has the variety been described in sufficient detail to allow a technical review by the MSU Plant Materials Release Committee?

7. Have there been offers for sale, sales or commercial distribution of this variety more than one year prior to the date the Plant Variety Disclosure Form was submitted?

8. Has every question on the Plant Variety Disclosure Form been answered? Please note that responses to all questions are required. Please indicate if the answer is not known or is not applicable.

9. Have all additional pages attached to the disclosure been marked “Confidential”?

10. Have the inventors/creators noted in Section 8 if they have received materials from colleagues at MSU (particularly if the colleagues are not listed as inventors on page 1 of the form) or from another institution which were used in the development of this variety? Have the inventors noted in Section 8 if they have received a request to fill out a Material Transfer Agreement from any other organization (university or company)?