1. If a person files an application with any board of county commissioners to fill a vacancy in the office of a Legislator pursuant to NRS 218A.262, the person must execute and file with his or her application a declaration of eligibility that must be in substantially the following form:

For the purpose of applying to fill the vacancy in the office of a Legislator in the following legislative district, ................ (name of assembly or senatorial district), I, the undersigned ................, do swear or affirm under penalty of perjury that I actually, as opposed to constructively, reside at ................, in the City or Town of ................, County of ................, State of Nevada; that, as required by NRS 218A.260, my actual, as opposed to constructive, residence in that legislative district began on a date at least 30 days immediately preceding the date established pursuant to NRS 218A.262 for the close of filing of applications to fill the vacancy; that my telephone number is ................, and the address at which I receive mail, if different than my residence, is ................; that I am registered as a member of the ................ Party; that I am a qualified elector pursuant to Section 1 of Article 2 of the Constitution of the State of Nevada; that if I have ever been convicted of treason or a felony, my civil rights have been restored; that I will otherwise qualify for the office if appointed thereto, including, but not limited to, complying with any limitation prescribed by the Constitution of this State concerning the number of years or terms for which a person may hold the office; that I understand that knowingly and willfully filing a declaration of eligibility which contains a false statement is a crime punishable as a gross misdemeanor; and that, as required by NRS 218A.200, I will have been an actual, as opposed to constructive, citizen resident of this State for 1 year immediately preceding the date of my appointment and that, during such period, I will have resided at the following residence or residences:

.......................................................... ...............................................................

Street Address Street Address

.......................................................... ...............................................................

City or Town City or Town

.......................................................... ...............................................................

State State

From................... To.................... From........................ To....................

Dates of Residency Dates of Residency

.......................................................... ...............................................................

Street Address Street Address

.......................................................... ...............................................................

City or Town City or Town

.......................................................... ...............................................................

State State

From................... To.................... From........................ To....................

Dates of Residency Dates of Residency

(Attach additional sheet or sheets of residences as necessary)

...............................................................................

(Name of applicant)

...............................................................................

(Signature of applicant)

Subscribed and sworn to before me

this ...... day of the month of ...... of the year ......

..................................................................

Notary Public or other person

authorized to administer an oath

2. Each address of the applicant that must be included in the declaration of eligibility pursuant to subsection 1 must be the street address of the residence where the applicant actually, as opposed to constructively, resided or resides in accordance with NRS 281.050, if one has been assigned. The declaration of eligibility must not be accepted for filing if any of the applicant’s addresses are listed as a post office box unless a street address has not been assigned to the residence.

3. Any person who knowingly and willfully files a declaration of eligibility that contains a false statement in violation of this section is guilty of a gross misdemeanor.

(Added to NRS by 2019, 882)