Page 2 of 2 – Consent to Adoption (child)
AFFIDAVIT OF WITNESSES
STATE OF NEVADA )
)
COUNTY OF CLARK )
On this (day) _______ day of (month) ___________________, 20_____, then and there
personally appeared the within named (first witness) __________________________________
and (second witness) __________________________________, who, being duly sworn, depose
and say: That they witnessed the execution of the within consent to adoption by (child’s name)
________________________________; 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 (child’s name) ___________________________ and in the presence
of each other and at the request of (child’s name) ________________________________; that at
the time of the execution of the consent to adoption (child’s name)
__________________________________ 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.
________________________________
(First Witness’s signature)
________________________________
(First Witness’s printed name)
________________________________
(Second Witness’s signature)
_________________________________
(Second Witness’s printed name)
SUBSCRIBED and SWORN to before
me this ______ day of
(month) ___________, (year) ________.
_________________________________
NOTARY PUBLIC
