State of Nevada Secretary of State Securities Division Child Support Information To: Office of the Secretary of State Securities Division 555 E. Washington Avenue, Suite 5200 Las Vegas, Nevada 89101 Pursuant to the mandates of Federal Welfare Reform legislation, the 1997 session of the Nevada Legislature passed SB356 which requires that professional and occupational licensing agencies add certain questions regarding child support to all applications for new licenses and renewals. The provisions of SB356 are effective October 1, 1997. Accordingly, the Division will NOT grant or renew any license after that date unless the following statement is completed and on file. Please be advised that NRS 90.600 provides that it is a Class C felony for anyone to file a false or misleading statement with the Division. Please mark the appropriate response (failure to mark one of the three responses will result in denial of the application). I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with the order or am in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order; or ____________ I am subject to a court order for the support of one or more children and am not in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. ________________________________________ Name of Applicant (printed) ________________________________________ Signature of Applicant ________________________________________ Date ________________________________________ Applicant’s Social Security Number PLEASE NOTE: IF YOU ARE NOT IN COMPLIANCE WITH YOUR CHILD SUPPORT OBLIGATIONS, YOU MUST SUBMIT A STATEMENT FROM YOUR LOCAL DISTRICT ATTORNEY OR OTHER CHILD SUPPORT AGENCY TO THE EFFECT THAT YOU HAVE MADE ARRANGEMENTS TO DISCHARGE SUCH OBLIGATIONS. American LegalNet, Inc. www.USCourtForms.com