Nevada Administrative Code
Chapter 50 - Witnesses
Section 50.050 - Form of affidavit regarding withdrawal of sample of blood

An affidavit referred to in subsection 4 of NRS 50.315 must be in substantially the following form:

State of Nevada }

}ss.

County of............................... }

I, ........................., being first duly sworn, depose and say:

That I am a ................ (occupation) employed by ................ (employer);

That a regular part of my duties is the withdrawing of blood samples from persons and I am authorized to do so by the ......................... (name of appropriate licensing or certifying agency);

That on ......................... (date) at ..... o'clock ...m., I withdrew a sample of blood in a medically accepted manner from a person known to me as ................ (name); and

That I kept the sample of blood in my sole custody or control and it remained in substantially the same condition as when I first obtained it until on ......................... (date) I delivered the sample to ................ (name of person) of the ................ (name of law enforcement agency).

I do hereby swear under penalty of perjury that the assertions of this affidavit are true.

...........................................................

Affiant's Signature

...........................................................

Affiant's Title

Subscribed and sworn to before me this

............. day of the month of ........... of the year ......

...................................................................................

Notary Public

Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A 7-18-88; R112-97, 5-26-98

NRS 50.315