SUPPLEMENTAL AFFIDAVIT (Per NAC 440.030)

PRINT FULL LEGAL NAME: ________________________________________________________________________________

Physical Address: ___________________________________________________________________________________________

City: ________________________________________ State: _________ Zip Code: ______________

E-mail Address: ______________________________________________________ Phone Number: _____________________

I, _____________________________________, certify and declare under penalty of perjury under the laws of the State of Nevada,

(Print Name)

that I have personal knowledge to attest to the information provided in the primary affidavit for ____________________________,

(Person of Record)

and I swear that all the assertions of this affidavit, including my identity, are true and accurate.

My relationship to the person of record is _________________________, and I have this personal knowledge through the

(Relationship)

following course of events: ___________________________________________________________________________________

__________________________________________________________________________________________________________

Signature: ___________________________________________

(Sign in the Presence of a Notary)

State of _________________,

County of ________________,

Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,

by ___________________________________________.

(Name of person making the statement)

The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within

instrument and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s signature on the

instrument, the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under penalty of perjury

under the laws of the State of Nevada that the foregoing paragraph is true and correct.

Notary Public: _________________________________ WITNESS my hand and official seal.

My Commission Expires: _________________________

_________________________________________

(Signature of Notary Public) Reserved for Notary Seal