IN THE MATTER OF A DECLARATION FOR PERSONAL INFORMATION MAINTAINED BY THE NEVADA SECRETARY OF STATE, WASHOE COUNTY CLERK, AND/OR CITY OF SPARKS CLERK TO REMAIN CONFIDENTIAL

DECLARATION OF   your name   , I declare under penalty of perjury, the following:

Specifically, I am (check one):

a) Any justice or judge in this State. 
b) Any senior justice or senior judge in this State.
c) Any court-appointed master or judicial officer in this State.
d) Any judicial personnel of an Indian tribe.
e) Any clerk of a court, court administrator, or court executive officer in this State.   
f) Any county or city clerk or registrar of voters charged with the powers and duties relating to elections and any deputy appointed by such county or city clerk or registrar of voters in the elections division of the county or city.
g) Any peace officer or retired peace officer.  
h) Any firefighter or retired firefighter.
i) Any prosecutor.  
j) Any state or county public defender.
k) Any person employed by the Office of the Attorney General who prosecutes or defends actions on behalf of the State of Nevada or any agency in the Executive Department of the State Government.  
l) Any person, including without limitation, a social worker, employed by this State or a political subdivision of this State who as part of his or her normal job responsibilities:

1. Interacts with the public; and
2. Performs tasks related to child welfare services or child protective services or tasks that expose the person to comparable dangers.

m) Any counter manager of this State.   
n) Any inspector, officer or investigator employed by this State or a political subdivision of this State designated by his or her employer;

1. Who possesses specialized training in code enforcement;
2. Who, as part of his or her normal job responsibilities, interacts with the public; and
3. Whose primary duties are the performance of tasks related to code enforcement.

o) Any civilian employee who provides support services to a law enforcement agency.  
p) Any provider of health care who practices in reproductive health.
q) Any employee of or volunteer for a health care facility that provides services related to reproductive health.  
r) Any provider of gender-affirming care.   
s) The spouse, domestic partner or minor child of a person described in paragraphs a)to l), inclusive.  
t) The surviving spouse, domestic partner or minor child of a person described in paragraphs a) to l), inclusive, who was killed in the performance of his or her duties.
u) Any person for whom a fictitious address has been issued pursuant to NRS 217.462 to 217.471, inclusive.                   

6. Confidentiality should attach to the following items of personal information:

Dated:   Date      
Signature:   Signature   
Print Name:   Name   
Address:   Address   
City, State, Zip:City, State, Zip