NEVADA STATE CONTRACTORS' BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
CHILD SUPPORT INFORMATION STATEMENT
In compliance with State and Federal law, applications applying for licensure as an Individual
are required complete and submit this Child Support Information Statement with their
application for contractor’s license.
Please mark the appropriate response and provide all other information requested on the form.
I am not subject to a Court Order for the support of a child.
I am subject to a Court Order for the support of one or more children and I am in
compliance with that Order; or I am in compliance with a plan approved by the District
Attorney or other public agency enforcing the Order for the repayment of the amount
owed pursuant to that Order.
I am subject to a Court Order for the support of one or more children and I am not in
compliance with the Order or a plan approved by the District Attorney or other public
agency enforcing the Order for the repayment of the amount owed pursuant to that
Order. Note: If you have marked this response you should contact the District Attorney
or other public agency enforcing the order to determine the actions that you may take to
satisfy the Order.
I certify, under penalty of perjury to the truth and accuracy of all statement contained herein.
____________________________
(Signature)
__________________________________________
(Print Name)
__________________________________________
(Social Security Number)
Date: _____________________________
