To: Register of Copyrights

Library of Congress

Washington, D.C. 20559

Re: Registration number _____________,

Class _______________,

issued to _________ (owner of copyright), _________(address of copyright owner)

Being owner of the previously mentioned copyright, I hereby make request, for a copy of the certificate of registration issued with respect to such copyright (pursuant to Title 37, Section 201.2(d)(1) of the Code of Federal Regulations). Enclosed with this request is a check in the amount of ______ payable to the Register of Copyrights, in payment of the required copying fee

Date: _________

Signature: _____________________ (copyright owner)