No ......... ... (month) ... (day) .... (year)
$..........
This is to certify that the (designating the town or city by its name) is indebted to ................ in the sum of ........ dollars principal, and ........ dollars interest, payable out of the debt service fund of ................; the principal sum of ........ dollars to bear interest from this date at the legal rate per annum, principal, interest, and accruing interest payable in lawful money of the United States.
.......................................................................,
Chair of the Board of County Commissioners
of .......................................... County, Nevada
...................................................................................
Clerk of ................ County, Nevada
All blanks shall be appropriately filled.
NRS 269.110