An unsworn declaration under NRS 53.250 to 53.390, inclusive, must be in substantially the following form:[Text not available]I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct, and that I am physically located outside the geographic boundaries of the United States, Puerto Rico, the United States Virgin Islands and any territory or insular possession subject to the jurisdiction of the United States.[Text not available]Executed on the _____ (date) day of ________ (month), _______ (year), at ___________________________ (city or other location and state), __________ (country).[Text not available][Text not available](printed name)[Text not available][Text not available][Text not available][Text not available]