Intervention Affidavit Form - Nevada Department Of Business And Industry Page 2
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4STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
2501 East Sahara Avenue, Suite 202 * Las Vegas, NV 89104-4137 * (702) 486-4480
E-mail:
CICOmbudsman@red.state.nv.us
INTERVENTION AFFIDAVIT
STATE OF NEVADA
COUNTY OF _______________________
Date: ___________________
I, _________________________________________ (Claimant), after being first duly sworn, state under penalty of
perjury and based upon personal knowledge:
1.
I have been aggrieved by an alleged violation of Chapter 116 of the Nevada Revised Statutes, Nevada
Administrative Code or the governing documents of the association. The person or entity who committed the
alleged violation is: ___________________________________________________________(Respondent).
2.
The Homeowners Association involved in this intervention affidavit is: ______________________________
Secretary of State entity # for the association is: _________________________________________________
(To locate File #: )
Address for the Homeowners Association: ____________________________________________________
Phone number for the Homeowners Association (President or other contact): ________________________
Name of President or contact for the Homeowners Association: ____________________________________
3.
I have provided the Respondent, _________________________________ via certified mail, return receipt
requested, with written notice of the exact issues listed in the intervention affidavit. I UNDERSTAND THAT IF
THE ALLEGATIONS (AND SUPPORTING FACTS) IN MY CERTIFIED LETTER DO NOT MATCH THE
ALLEGATIONS (AND SUPPORTING FACTS) DESCRIBED IN #7 BELOW, THOSE ISSUES WILL NOT
BE CONSIDERED AS PART OF MY COMPLAINT.
4.
The written notice specified, in reasonable detail, the alleged violation, any actual damages I suffered as a result
of the alleged violation, and the corrective action I proposed, if any.
5.
The notice referred to in # 3 was mailed to the respondent’s last known address.
6.
_________ (initials required) Attached to the Affidavit as Exhibit “1” is a copy of the certified letter sent to
respondent AND stapled to that letter is the certified return receipt from the post office. This may constitute
evidence that the respondent has been given a reasonable opportunity, after receipt of the written notice, to correct
the alleged violation.
Revised 08/11/11
Page 2 of 4
530
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