Section 215 Declaration as to Non-Prejudicial Disclosures or Exceptions to Lack of Novelty 
Any declaration as to non-prejudicial disclosures or exceptions to lack of novelty shall be worded as follows, with such inclusion, omission, repetition and re-ordering of the matters listed as items (i) to (iv) as is necessary:
"Declaration as to non-prejudicial disclosures or exceptions to lack of novelty (Rules 4.17(v) and 51bis.1(a)(v) ):
in relation to [this] international application [No. PCT/…],
… (name) declares that the subject matter claimed in [the] [this] international application was disclosed as follows:
(i) kind of disclosure (include as applicable):
(a) international exhibition
(b) publication
(c) abuse
(d) other: ...(specify)
(ii) date of disclosure: ...
(iii) title of disclosure (if applicable): ...
(iv) place of disclosure (if applicable): ..."