1 CODE: 1075 Name:_________________________ 2 Address:_______________________ ______________________________ 3 Telephone:_____________________ Acting In Proper Person 4 5 6 IN THE FAMILY DIVISION 7 OF THE SECOND JUDICIAL COURT OF THE STATE OF NEVADA 8 IN AND FOR THE COUNTY OF WASHOE 9 10 ________________________________ (Plaintiff/Petitioner) 11 12 vs Case No. ___________________13 ________________________________ Dept. No. ___________________ (Defendant/Respondent) 14 ____________________________________/ 15 16 AFFIDAVIT OF 17 STATE OF ____________________) 18 )ss: County of______________________) 19 _______________________________________, being first duly sworn under penalties20 of perjury, deposes and says: 21 I have personal knowledge of the following: 22 ________________________________________________________________________________ 23 ________________________________________________________________________________ 24 ________________________________________________________________________________ 25 ________________________________________________________________________________ 26 ________________________________________________________________________________ 27 28 1 >>>> 2 1 ________________________________________________________________________________ 2 ________________________________________________________________________________ 3 ________________________________________________________________________________ 4 ____________________________________________________________________________________ 5 ________________________________________________________________________________ 6 ________________________________________________________________________________ 7 ________________________________________________________________________________ 8 ________________________________________________________________________________ 9 ________________________________________________________________________________10 ____________________________________________________________________________________11 ________________________________________________________________________________12 ________________________________________________________________________________13 ________________________________________________________________________________14 ________________________________________________________________________________15 ________________________________________________________________________________16 ____________________________________________________________________________________17 DATE:_______________________________ 18 _______________________________________ (Signature)19 ________________________________________20 (Address)21 _________________________________________22 _______________________________________23 (Telephone) SUBSCRIBED and SWORN to before me 24 this ______day of _________________, ________ 25 26 _________________________________________ NOTARY PUBLIC 27 28 2