State of Nevada }
}ss.
County of................................... }
................................, 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:
.......................................................................................................................................................
.......................................................................................................................................................
...............................................................
(Signature)
Subscribed and sworn to before me
this ...... day of the month of ...... of the year ......
...............................................................................
Notary Public (or other person
authorized to administer oaths)
NRS 362.050