Request For Mediation/arbitration And Property Owner'S Statement - State Of Utah
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1
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4State of Utah
Department of Commerce
O
P
R
O
FFICE OF THE
ROPERTY
IGHTS
MBUDSMAN
GARY R. HERBERT
Request for Mediation/Arbitration and
Governor
SPENCER J. COX
Property Owner’s Statement
Lieutenant Governor
Please return by regular mail to:
Or by email or fax to:
PO Box 146702
Fax: (801) 530-6338
Salt Lake City, UT 84114
Email: propertyrights@utah.gov
See the attached instructions for more information and assistance in completing this form.
_______________________________________________________________________
Name of Property Owner Requesting Mediation and/or Arbitration
_______________________________________________________________________
Representative of Property Owner or other contact person (if applicable)
Type of Representative
_______________________________________________________________________
Mailing Address, City, State, Zip Code (of property owner or the contact person)
_______________________________________________________________________
Telephone - Day
Telephone - Evening
Email
What is the location (address) of the property involved in this dispute?
_______________________________________________________________________
What government entity is involved in this dispute?
_______________________________________________________________________
Name of City, County, Special District, State Agency or Other Entity
_______________________________________________________________________
Street Address, City, State, Zip Code
_______________________________________________________________________
Agency contact person
Title
Telephone
Email
What type of dispute is it?
_______________________________________________________________________
- 1 -
Rev 4-14
Telephone: (801) 530-6391 • Facsimile (801) 530-6338 • propertyrights.utah.gov
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