Forms • Churchill County, NV • CivicEngage

Parcel Number:*

Is the owner information on the declaration correct?*

Yes

No

If NO, complete the changes below:

Owner Name:

Legal/Corporation Name:

Mailing Address:

Is the water rights information on the declaration correct?*

Yes

No

If NO, complete the changes below:

Deeded Water Rights:

TCID Water Righted Acres:

TCID Serial Number:

State Permit #:

Farm Unit?

Yes

No

If YES, Farm Unit #:

Do any of the following apply?

Water Rights Purchased

Yes

No

Date Purchased:

Purchased From:

TCID S/N or Permit #:

Water Rights Sold

Yes

No

Date Sold:

New Owner:

TCID S/N or Permit #:

Water Rights Leased

Yes

No

Date Leased:

Leased to:

TCID S/N or Permit #:

Contact Information:

Preparer Name:

Title:

Company Name:

Address:

Phone Number:

Email Address:

Provide any addition information that may be relevant to the water right information on the above listed parcel. (Example: no delivery, disputes, etc.)

OATH: Under penalty of perjury, I do hereby solemnly and truthfully declare and affirm that I have examined this water rights declaration and any changes made therein are to the best of my knowledge and belief it is truly correct and complete.

Signature:*

Print Name:*

Date:*

Phone #:*

* indicates required fields.

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