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) NAC 50.035 Form of declaration regarding preparation of solution or gas used in calibrating breath-testing device. (NRS 50.315) A declaration which is referred to in subsection 2 of NRS 50.315 must be in substantially the following form: I, ..........................................., hereby declare: That I am a ............... (occupation) employed by ................ (employer); That on ......................... (date) I prepared a ............... (chemical solution or gas) consisting of ................ (description and composition of solution or gas) as necessary for accurately calibrating the ................ (name of device). I declare under penalty of perjury that the foregoing is true and correct. Executed on ... (Date) (Declarant’s Signature) (Declarant’s Title) (Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5?26?98) NAC 50.040 Form of affidavit regarding calibration of breath-testing device. (NRS 50.315) An affidavit referred to in subsection 3 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 forensic analyst of alcohol employed by ................ (name of employer); That I was certified by the director of the department of public safety on ......................... (date) as a person competent to calibrate evidential breath-testing devices; That on ......................... (date) I calibrated a ................ (name of device) bearing serial number ........ which is located at the ................ (name of law enforcement agency) in ................ (city or county), Nevada; That the ................ (name of device) is certified by the committee on testing for intoxication, as designed and manufactured, to be accurate and reliable for the purpose of testing a person’s breath to determine the concentration of alcohol in the person’s breath (grams per 210 liters of breath); That the calibration was performed by verifying the response and accuracy of the device, as prescribed in the regulations of the committee on testing for intoxication, by ................ (description of procedure used); That the calibration was performed within the period required and that the device was otherwise maintained as required by the regulations of the committee on testing for intoxication; and That upon completion of the calibration the ................ (name and serial number of device) was operating properly. 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 11?23?93; 9?9?94; R112?97, 5?26?98; R137?99, 12?13?99) NAC 50.045 Form of declaration regarding calibration of breath-testing device. (NRS 50.315) A declaration referred to in subsection 3 of NRS 50.315 must be in substantially the following form: I, ..........................................., hereby declare: That I am a forensic analyst of alcohol employed by ................ (name of employer); That I was certified by the director of the department of public safety on ......................... (date) as a person competent to calibrate evidential breath-testing devices; That on ......................... (date) I calibrated a ................ (name of device) bearing serial number ........ which is located at the ................ (name of law enforcement agency) in ................ (city or county), Nevada; That the ................ (name of device) is certified by the committee on testing for intoxication, as designed and manufactured, to be accurate and reliable for the purpose of testing a person’s breath to determine the concentration of alcohol in the person’s breath (grams per 210 liters of breath); That the calibration was performed by verifying the response and accuracy of the device, as prescribed in the regulations of the committee on testing for intoxication, by ................ (description of procedure used); That the calibration was performed within the period required and that the device was otherwise maintained as required by the regulations of the committee on testing for intoxication; and That upon completion of the calibration the ................ (name and serial number of device) was operating properly. I declare under penalty of perjury that the foregoing is true and correct. Executed on ... (Date) (Declarant’s Signature) (Declarant’s Title) (Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5?26?98; A by R137?99, 12?13?99) NAC 50.050 Form of affidavit regarding withdrawal of sample of blood. (NRS 50.315) 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) NAC 50.055 Form of declaration regarding withdrawal of sample of blood. (NRS 50.315) A declaration referred to in subsection 4 of NRS 50.315 must be in substantially the following form: I, ................., hereby declare: 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 declare under penalty of perjury that the foregoing is true and correct. Executed on ...

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