Intervention Affidavit Form - Nevada Department Of Business And Industry Page 4

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STATE 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
COMPLAINT:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
SUPPORTING LAW AND/OR GOVERNING DOCUMENT:
__________________________________________________________________________________________
__________________________________________________________________________________________
RESOLUTION:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
BRIEF STATEMENT OF FACTS:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I have read the foregoing Affidavit consisting of
pages (including all additional attached pages), and
it is true and correct to the best of my knowledge and belief.
(Signature of complainant) _____________________________
Name ______________________________________________
Street Address _______________________________________
City, State, Zip _______________________________________
Area Code __________ Phone__________________________
Subscribed and sworn to before me
This ___ day of _____________, 20____.
__________________________________NOTARY PUBLIC
Revised 08/11/11
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