[Rev. 11/21/2013 3:46:22 PM--2013]
[NAC-50 Revised Date: 7-11]
50.010 Form of affidavit regarding presence, identity or amount of alcohol, controlled substance, chemical, poison, organic solvent or other prohibited substance in blood or urine of person.
50.015 Form of declaration regarding presence, identity or amount of alcohol, controlled substance, chemical, poison, organic solvent or other prohibited substance in blood or urine of person.
50.020 Form of affidavit regarding competence of person to operate certified breath-testing device and regarding identity of person from whom affiant obtained sample.
50.025 Form of declaration regarding competence of person to operate certified breath-testing device and regarding identity of person from whom affiant obtained sample.
50.030 Form of affidavit regarding preparation of solution or gas used in calibrating breath-testing device.
50.035 Form of declaration regarding preparation of solution or gas used in calibrating breath-testing device.
50.040 Form of affidavit regarding calibration of breath-testing device.
50.045 Form of declaration regarding calibration of breath-testing device.
50.050 Form of affidavit regarding withdrawal of sample of blood.
50.055 Form of declaration regarding withdrawal of sample of blood.
50.060 Form of affidavit regarding custody of sample or other evidence.
50.065 Form of declaration regarding custody of sample or other evidence.
NAC 50.010 Form of affidavit regarding presence, identity or amount of alcohol, controlled substance, chemical, poison, organic solvent or other prohibited substance in blood or urine of person. (NRS 50.320) An affidavit of an expert referred to in NRS 50.320 must be substantially in one of the following forms:
1. If the sample or substance contained a controlled substance as defined in chapter 453 of NRS or a chemical, poison, organic solvent or another prohibited substance:
State of Nevada }
}ss.
County of............................... }
I, ..........................................., being first duly sworn, depose and say:
That I am ................ (occupation) employed by ................ (employer);
That on ......................... (date) I first qualified in the ................ Court of ................ County, Nevada, a court of record, as an expert witness for the purpose of testifying regarding the presence and identity in the blood or urine of a person of a controlled substance the use or possession of which is regulated by chapter 453 of NRS or a chemical, poison, organic solvent or another prohibited substance, or the identity of a controlled substance alleged to have been in the possession of a person;
That on ......................... (date) I obtained certain evidence from ................ (person, or evidence vault in sealed container), the evidence bearing Identification No. ...... of ................ (agency) and consisting of ................ for the purpose of performing a chemical analysis on the contents thereof;
That on ......................... (date) I analyzed the sample or substance and determined it to be or contain ................ (name of controlled substance, chemical, poison, organic solvent or other prohibited substance);
That on ......................... (date) I replaced the sample or substance in its container and sealed the container with a seal bearing my initials .....;
That the evidence was in my sole custody or control from the time I obtained it until I resealed its container, at which time it was in substantially the same condition as when I first obtained it; and
That on ......................... (date) I returned the evidence to ................ (person or evidence vault) or that I still have the evidence in my possession.
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
2. If the sample contained alcohol:
State of Nevada }
}ss.
County of............................... }
I, .........................................., being first duly sworn, depose and say:
That I am ................ (occupation) employed by ................ (employer);
That on ......................... (date) I first qualified in the ................ Court of ................ County, Nevada, a court of record, as an expert witness for the purpose of testifying regarding the presence and amount of alcohol in the blood or urine of a person;
That on ......................... (date) I obtained evidence from ................ (person, or evidence vault in sealed container), the evidence bearing Identification No. ...... of ................ (agency) and consisting of a sample of ........ (blood or urine);
That on ......................... (date) I analyzed the sample and determined that the blood of the person from whom the sample was taken contained a concentration of alcohol of ..... (grams per 100 milliliters of blood);
That on ......................... (date) I replaced the sample in its container and sealed the container with a seal bearing my initials .....;
That the evidence was in my sole custody or control from the time I first obtained it until I resealed its container, at which time it was in substantially the same condition as when I first obtained it; and
That on ......................... (date) I returned the evidence to ................ (person or evidence vault) or that I still have the evidence in my possession.
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
(Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A by R112-97, 5-26-98; R137-99, 12-13-99; R140-10, 5-5-2011)
NAC 50.015 Form of declaration regarding presence, identity or amount of alcohol, controlled substance, chemical, poison, organic solvent or other prohibited substance in blood or urine of person. (NRS 50.320) A declaration of an expert referred to in NRS 50.320 must be substantially in one of the following forms:
1. If the sample or substance contained a controlled substance as defined in chapter 453 of NRS or a chemical, poison, organic solvent or another prohibited substance:
I, ..........................................., hereby declare:
That I am ................ (occupation) employed by ................ (employer);
That on ......................... (date) I first qualified in the ................ Court of ................ County, Nevada, a court of record, as an expert witness for the purpose of testifying regarding the presence and identity in the blood or urine of a person of a controlled substance the use or possession of which is regulated by chapter 453 of NRS or a chemical, poison, organic solvent or another prohibited substance, or the identity of a controlled substance alleged to have been in the possession of a person;
That on ......................... (date) I obtained certain evidence from ................ (person, or evidence vault in sealed container), the evidence bearing Identification No. ..... of ................ (agency) and consisting of ................ for the purpose of performing a chemical analysis on the contents thereof;
That on ......................... (date) I analyzed the sample or substance and determined it to be or contain ................ (name of controlled substance, chemical, poison, organic solvent or another prohibited substance);
That on ......................... (date) I replaced the sample or substance in its container and sealed the container with a seal bearing my initials .....;
That the evidence was in my sole custody or control from the time I obtained it until I resealed its container, at which time it was in substantially the same condition as when I first obtained it; and
That on ......................... (date) I returned the evidence to ................ (person or evidence vault) or that I still have the evidence in my possession.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
2. If the sample contained alcohol:
I, .........................................., hereby declare:
That I am ................ (occupation) employed by ................ (employer);
That on ......................... (date) I first qualified in the ................ Court of ................ County, Nevada, a court of record, as an expert witness for the purpose of testifying regarding the presence and amount of alcohol in the blood or urine of a person;
That on ......................... (date) I obtained evidence from ................ (person, or evidence vault in sealed container), the evidence bearing Identification No. ..... of ................ (agency) and consisting of a sample of ........ (blood or urine);
That on ......................... (date) I analyzed the sample and determined that the blood of the person from whom the sample was taken contained a concentration of alcohol of ..... (grams per 100 milliliters of blood);
That on ......................... (date) I replaced the sample in its container and sealed the container with a seal bearing my initials .....;
That the evidence was in my sole custody or control from the time I first obtained it until I resealed its container, at which time it was in substantially the same condition as when I first obtained it; and
That on ......................... (date) I returned the evidence to ................ (person or evidence vault) or that I still have the evidence in my possession.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
(Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98; A by R137-99, 12-13-99; R140-10, 5-5-2011)
NAC 50.020 Form of affidavit regarding competence of person to operate certified breath-testing device and regarding identity of person from whom affiant obtained sample. (NRS 50.315) An affidavit which is referred to in subsection 1 of NRS 50.315 must be in substantially the following form:
State of Nevada }
}ss.
County of............................... }
I, .............................., being first duly sworn, depose and say:
That I am ................ (occupation) employed by ............. (employer);
That I was certified on ......................... (date) by the Director of the Department of Public Safety as being competent to operate a ................ (name of breath-testing device), a device of a type which, as designed and manufactured, has been certified by the Committee on Testing for Intoxication to be accurate and reliable for testing a person’s breath to determine the concentration of alcohol in his or her breath;
That on ......................... (date) I obtained a sample of the breath of ................ (name of person tested) and tested it in accordance with the prescribed checklist on a ................ (name of device) which was functioning properly; and
That the tests indicated the breath of the person tested contained the following concentrations of alcohol (grams per 210 liters of breath):
1st test …….. 2nd test …….. 3rd test ……..
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
(Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A 11-23-93; 9-9-94; R112-97, 5-26-98; R137-99, 12-13-99)
NAC 50.025 Form of declaration regarding competence of person to operate certified breath-testing device and regarding identity of person from whom affiant obtained sample. (NRS 50.315) A declaration which is referred to in subsection 1 of NRS 50.315 must be in substantially the following form:
I, ..........................................., hereby declare:
That I am ................ (occupation) employed by ............. (employer);
That I was certified on ......................... (date) by the Director of the Department of Public Safety as being competent to operate a ................ (name of breath-testing device), a device of a type which, as designed and manufactured, has been certified by the Committee on Testing for Intoxication to be accurate and reliable for testing a person’s breath to determine the concentration of alcohol in his or her breath;
That on ......................... (date) I obtained a sample of the breath of ................ (name of person tested) and tested it in accordance with the prescribed checklist on a ................ (name of device) which was functioning properly; and
That the tests indicated the breath of the person tested contained the following concentrations of alcohol (grams per 210 liters of breath):
1st test ……… 2nd test ……… 3rd test ………
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
(Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98; A by R137-99, 12-13-99)
NAC 50.030 Form of affidavit regarding preparation of solution or gas used in calibrating breath-testing device. (NRS 50.315) An affidavit which is referred to in subsection 2 of NRS 50.315 must be in substantially the following form:
State of Nevada }
}ss.
County of............................... }
I, ........................., being first duly sworn, depose and say:
That I am a ............... (occupation) employed by ................ (employer);
That on ......................... (date) I prepared a ............... (chemical solution or gas) consisting of ................ (description and composition of solution or gas) as necessary for accurately calibrating the ................ (name of device).
I do hereby swear under penalty of perjury that the assertions of this affidavit are true.
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
(Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A 7-18-88; R112-97, 5-26-98)
NAC 50.035 Form of declaration regarding preparation of solution or gas used in calibrating breath-testing device. (NRS 50.315) A declaration which is referred to in subsection 2 of NRS 50.315 must be in substantially the following form:
I, ..........................................., hereby declare:
That I am a ............... (occupation) employed by ................ (employer);
That on ......................... (date) I prepared a ............... (chemical solution or gas) consisting of ................ (description and composition of solution or gas) as necessary for accurately calibrating the ................ (name of device).
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
(Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98)
NAC 50.040 Form of affidavit regarding calibration of breath-testing device. (NRS 50.315) An affidavit referred to in subsection 3 of NRS 50.315 must be in substantially the following form:
State of Nevada }
}ss.
County of............................... }
I, .........................., being first duly sworn, depose and say:
That I am a forensic analyst of alcohol employed by ................ (name of employer);
That I was certified by the Director of the Department of Public Safety on ......................... (date) as a person competent to calibrate evidential breath-testing devices;
That on ......................... (date) I calibrated a ................ (name of device) bearing serial number ........ which is located at the ................ (name of law enforcement agency) in ................ (city or county), Nevada;
That the ................ (name of device) is certified by the Committee on Testing for Intoxication, as designed and manufactured, to be accurate and reliable for the purpose of testing a person’s breath to determine the concentration of alcohol in the person’s breath (grams per 210 liters of breath);
That the calibration was performed by verifying the response and accuracy of the device, as prescribed in the regulations of the Committee on Testing for Intoxication, by ................ (description of procedure used);
That the calibration was performed within the period required and that the device was otherwise maintained as required by the regulations of the Committee on Testing for Intoxication; and
That upon completion of the calibration the ................ (name and serial number of device) was operating properly.
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
(Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A 11-23-93; 9-9-94; R112-97, 5-26-98; R137-99, 12-13-99)
NAC 50.045 Form of declaration regarding calibration of breath-testing device. (NRS 50.315) A declaration referred to in subsection 3 of NRS 50.315 must be in substantially the following form:
I, ..........................................., hereby declare:
That I am a forensic analyst of alcohol employed by ................ (name of employer);
That I was certified by the Director of the Department of Public Safety on ......................... (date) as a person competent to calibrate evidential breath-testing devices;
That on ......................... (date) I calibrated a ................ (name of device) bearing serial number ........ which is located at the ................ (name of law enforcement agency) in ................ (city or county), Nevada;
That the ................ (name of device) is certified by the Committee on Testing for Intoxication, as designed and manufactured, to be accurate and reliable for the purpose of testing a person’s breath to determine the concentration of alcohol in the person’s breath (grams per 210 liters of breath);
That the calibration was performed by verifying the response and accuracy of the device, as prescribed in the regulations of the Committee on Testing for Intoxication, by ................ (description of procedure used);
That the calibration was performed within the period required and that the device was otherwise maintained as required by the regulations of the Committee on Testing for Intoxication; and
That upon completion of the calibration the ................ (name and serial number of device) was operating properly.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
(Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98; A by R137-99, 12-13-99)
NAC 50.050 Form of affidavit regarding withdrawal of sample of blood. (NRS 50.315) An affidavit referred to in subsection 4 of NRS 50.315 must be in substantially the following form:
State of Nevada }
}ss.
County of............................... }
I, ........................., being first duly sworn, depose and say:
That I am a ................ (occupation) employed by ................ (employer);
That a regular part of my duties is the withdrawing of blood samples from persons and I am authorized to do so by the ......................... (name of appropriate licensing or certifying agency);
That on ......................... (date) at ..... o’clock ...m., I withdrew a sample of blood in a medically accepted manner from a person known to me as ................ (name); and
That I kept the sample of blood in my sole custody or control and it remained in substantially the same condition as when I first obtained it until on ......................... (date) I delivered the sample to ................ (name of person) of the ................ (name of law enforcement agency).
I do hereby swear under penalty of perjury that the assertions of this affidavit are true.
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
(Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A 7-18-88; R112-97, 5-26-98)
NAC 50.055 Form of declaration regarding withdrawal of sample of blood. (NRS 50.315) A declaration referred to in subsection 4 of NRS 50.315 must be in substantially the following form:
I, ................., hereby declare:
That I am a ................ (occupation) employed by ................ (employer);
That a regular part of my duties is the withdrawing of blood samples from persons and I am authorized to do so by the ......................... (name of appropriate licensing or certifying agency);
That on ......................... (date) at ..... o’clock ...m., I withdrew a sample of blood in a medically accepted manner from a person known to me as ................ (name); and
That I kept the sample of blood in my sole custody or control and it remained in substantially the same condition as when I first obtained it until on ......................... (date) I delivered the sample to ................ (name of person) of the ................ (name of law enforcement agency).
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
(Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98)
NAC 50.060 Form of affidavit regarding custody of sample or other evidence. (NRS 50.315) An affidavit referred to in subsection 5 of NRS 50.315 must be in substantially the following form:
State of Nevada }
}ss.
County of............................... }
I, ........................., being first duly sworn, depose and say:
That I am a ................ (occupation) employed by ................ (employer);
That on ......................... (date) I received from ................ (name of person) certain evidence bearing Identification No. ..... of the ................ (law enforcement agency), consisting of ................ (description of evidence); and
That I kept the evidence in my sole custody or control and in substantially the same condition as when I first received it until on ......................... (date) when I delivered the evidence to ................ (name of person).
...........................................................
Affiant’s Signature
...........................................................
Affiant’s Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
(Added to NAC by Com. on Testing for Intoxication, eff. 10-26-83; A by R112-97, 5-26-98)
NAC 50.065 Form of declaration regarding custody of sample or other evidence. (NRS 50.315) A declaration referred to in subsection 5 of NRS 50.315 must be in substantially the following form:
I, ................., hereby declare:
That I am a ................ (occupation) employed by ................ (employer);
That on ......................... (date) I received from ........ (name of person) certain evidence bearing Identification No. ..... of the ............. (law enforcement agency), consisting of ............... (description of evidence); and
That I kept the evidence in my sole custody or control and in substantially the same condition as when I first received it until on ......................... (date) when I delivered the evidence to ............... (name of person).
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant’s Signature)
.............................................................................
(Declarant’s Title)
(Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98)