Registration Number:

PA 8-765-432
*138962643*
Effective date of
registration:

May 12, 2005

Title
Title of Work: Our Summer Vacations

Previous or Alternative Title(s): Our Trip to Florida

Nature of Work: Motion Picture

Completion/Publication
Year of Completion: 2005
Date of 1st Publication: April 1, 2005 Nation of 1st Publication: United States

Author
Author: Mary Smith

Sample 2
Nature of Authorship: Shot home video
Work made for hire: No
Citizen of: United States Domiciled in: United States
Year Born: 1965
Anonymous: No Pseudonymous: No

Author: Bob Smith

Nature of Authorship: Shot and edited video

Work made for hire: No

Citizen of: Australia Domiciled in: United States
Year Born: 1970
Anonymous: No Pseudonymous: No

Copyright claimant
Copyright Claimant: John Jones
4321 Main Street, New York, NY 10234
Transfer Statement: By assignment

PA 8-765-432 Page 1 of 2
Limitation of copyright claim
Material excluded from this claim: Previously registered home video
Previously registered: Yes
Previous registration and year: PAu 6-123-456 2004
Basis of current registration: This is a changed version of the work.
New material included in claim: New video and editing

Certification
Name: Mary Jones, author, authorized agent of Smith Jones
Productions, Inc.
Date: May 9, 2005

Correspondence: Yes
Copyright Office notes: Regarding publication: Year date in copyright notice is 2003.

Sample 2

PA 8-765-432 Page 2 of 2