No ......... ... (month) ... (day) ... (year)
The county treasurer of ................ County will pay to ................. the sum of ........ dollars, for (stating in general terms the nature of the claim), and charge the same to the general fund of the (town or city of) ................
$......... ................................... County Auditor
The county auditor shall appropriately fill all blanks.
NRS 269.105