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For Renewal of Work (United States)

This is a copyright form for renewal of a work. The form provided here is simply a sample of what the actual Form RE looks like.

FORM RE

For Renewal of a Work

UNITED STATES COPYRIGHT OFFICE

REGISTRATION NUMBER ___________________________

EFFECTIVE DATE OF RENEWAL REGISTRATION

_______________________ Month _______________ Day __________ Year

DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET (FORM RE/CON).

1 RENEWAL CLAIMANT(S), ADDRESS(ES), AND STATEMENT OF CLAIM (See Instructions) (Use appropriate statement from instructions)

a Name ___________________________

Address ___________________________

___________________________

Claiming as ___________________________

b Name ___________________________

Address ___________________________

___________________________

Claiming as ___________________________

c Name ___________________________

Address ___________________________

___________________________

Claiming as ___________________________

2 TITLE OF WORK IN WHICH RENEWAL IS CLAIMED

___________________________

RENEWABLE MATTER ___________________________

PUBLICATION AS A CONTRIBUTION If this work was published as a contribution to a periodical, serial, or other composite work, give information about the collective work in which the contribution appeared.

Title of Collective Work ___________________________

If published in a periodical or serial give:

___________________________ Volume

___________________________ Number

___________________________ Issue Date

3 AUTHOR(S) OF RENEWABLE MATTER ___________________________

4 ORIGINAL REGISTRATION NUMBER ___________________________

ORIGINAL COPYRIGHT CLAIMANT ___________________________

ORIGINAL DATE OF COPYRIGHT ___________________________

If the original registration for this work was made in unpublished form, give:

DATE OF PUBLICATION:

___________________ (Month) ________________ (Day) ________ (Year)

OR

If the original registration for this work was made in published form, give:

DATE OF REGISTRATION:

__________________ (Month) __________________ (Day) _________ (Year)


• Complete all applicable spaces (numbers 5-8) on the reverse side of this page.
• See detailed instructions.
• Sign the form at space 7.


RENEWAL APPLICATION RECEIVED ___________________________

CORRESPONDENCE ❑ YES

EXAMINED BY ___________________________

CHECKED BY ___________________________

FUNDS RECEIVED ___________________________

FOR COPYRIGHT OFFICE USE ONLY

DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET (FORM RE/CON).

5 RENEWAL FOR GROUP OF WORKS BY SAME AUTHOR: To make a single registration for a group of works by the same individual author published as contributions to periodicals (see instructions), give full information about each contribution. If more space is needed, request continuation sheet (Form RE/CON).

a Title of Contribution: ___________________________

Title of Periodical: ___________________________

Vol: ___________________________

No: ___________________________

Issue Date: ___________________________

Date of Publication: ___________________________

Registration Number: ___________________________

b Title of Contribution: ___________________________

Title of Periodical: ___________________________

Vol: ___________________________

No: ___________________________

Issue Date: ___________________________

Date of Publication: ___________________________

Registration Number: ___________________________

6 DEPOSIT ACCOUNT: If the registration fee is to be charged to a Deposit Account established in the Copyright Office, give name and number of Account.

Name ___________________________

Account Number ___________________________

Area code and daytime telephone number ___________________________

CORRESPONDENCE: Give name and address to which correspondence about this application should be sent.

Name ___________________________

Address ___________________________

___________________________

Fax number ___________________________

Email Address ___________________________

7 CERTIFICATION* I, the undersigned, hereby certify that I am the: (Check one)

❑ renewal claimant

❑ duly authorized agent of ___________________________ (Name of renewal claimant)

of the work identified in this application and that the statements made by me in this application are correct to the best of my knowledge.

Typed or printed name ___________________________

Date ___________________________

Handwritten signature (X) ___________________________

8 Certificate will be mailed in window envelope to this address:

Name ___________________________

Number/Street/Apt ___________________________

City/State/ZIP ___________________________

YOU MUST:

• Complete all necessary spaces
• Sign your application in space 7

SEND ALL ELEMENTS IN THE SAME PACKAGE:

1. Application form
2. Nonrefundable filing fee in check or money order payable to Register of Copyrights

MAIL TO:

Library of Congress
Copyright Office
101 Independence Avenue, S.E.
Washington, D.C. 20559-6000

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