State of Nevada | } | |
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County of................................................ | } |
(Date)................................................................
Then and there personally appeared the within-named ................ and ................, who, being duly sworn, depose and say: That they witnessed the execution of the within consent to adoption by ................ (name of person or persons consenting); that she, he or they subscribed the consent to adoption and declared the same to be a voluntary consent to adoption in their presence; that at the time the consent to adoption was executed it contained the names of the person or persons to whom consent was thereby given to adopt the child; that they thereafter subscribed the same as witnesses in the presence of ................ (name of person or persons consenting) and in the presence of each other and at the request of ................ (name of person or persons consenting); that at the time of the execution of the consent to adoption ................ (name of person or persons consenting) acknowledged to them that she, he or they was or were, and she, he or they appeared to them to be, in full possession of her, his or their faculties and not under the influence of any drug or sedative or subject to any duress, fear, menace, compulsion or undue influence whatever; and that they make this affidavit at her, his or their request.
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Subscribed and sworn to before me
this ...... day of the month of ...... of the year ......
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Notary Public
NRS 127.055