Intellectual Property Income Distribution Form



The University of North Texas Health Science Center at Fort Worth’s Intellectual Property Policy requires researchers who contribute jointly to intellectual property to agree between themselves the proportion to which each will be entitled from the net revenue payable to researchers according to the revenue sharing procedures defined in the UNTHSC IP Policy.

Contributors are asked to state below the relative percentage share of researchers’ benefits due to each. This percentage will be taken as indicative of the relative value of the contribution of each.

| | |

|Title of Disclosure or Patent | |

|Application | |

| | |

We, the undersigned, agree that our individual contributions to the intellectual property named above were, at the time of signature, as follows and we elect to receive distributions per UNTHSC policy.

|Originator’s Name(s) |Distribution |Signature |Date |US Citizen? |

| |% | | | |

|1. _____________________________ |__________ |___________________________ |______________ | Yes |

|Dept/Service Unit: _________________________________________ | No |

|2. _____________________________ |__________ |___________________________ |______________ | Yes |

|Dept/Service Unit: _________________________________________ | No |

|3. _____________________________ |__________ |___________________________ |______________ | Yes |

|Dept/Service Unit: _________________________________________ | No |

|4. _____________________________ |__________ |___________________________ |______________ | Yes |

|Dept/Service Unit: _________________________________________ | No |

| |Total 100% | | | |

Distribution Waiver

I, ________________________________________ wish to waive my personal distribution and direct it to the

Lab of __________________________________________________________ or

Department of ___________________________________________________

RECEIVED: ________________________________________________ ______________ Robert McClain, Ph.D. Date Received

Associate Vice President

Technology Transfer and Commercialization

Royalties can be distributed only after this form has been completed. UNTHSC employees will be paid by check.

1099 forms will be issued at the end of the year by the Payroll Department.

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