Nevada Revised Statutes Title 32. Revenue and Taxation § 362.050. Affidavit of labor: Requirement for exemption of surface of patented mine or mining claim from taxation; form and contents

_______________, being first duly sworn, deposes and says: That development work worth at least $100 was performed upon the _______________ patented mine or mining claim, situated in the _______________ Mining District, County of _______________, State of Nevada, during the federal mining assessment work period ending within the year _____. The work was done at the expense of _______________, the owner (or one of the owners) of the patented mine or mining claim, for the purpose of relieving it from the tax assessment. It was performed by _______________, at about __________ feet in a __________ direction from the monument of location, and was done between the _____ day of the month of _____ of the year _____, and the _____ day of the month of _____ of the year _______________, and consisted of the following work: