Form 668 - Application For Mediation

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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS PROGRAM
1179 Fairview Drive, Suite E * Carson City, NV 89701-5453 * (775) 687-4280
2501 East Sahara Avenue, Suite 205 * Las Vegas, NV 89104-4137
(702) 486-4480 * Toll free: (877) 829-9907
E-mail:
CICOmbudsman@red.nv.gov
ALTERNATIVE DISPUTE RESOLUTION (ADR)
SUBSIDY APPLICATION FOR MEDIATION
IMPORTANT: Subsidization of any Mediator fees is limited to actual Mediator fees only and may not exceed $250.00 per side not to
exceed $500 per Mediation, to the extent that funds are available. Specific costs not subsidized include, but are not limited to, the
$50 filing fee required to accompany any claim or response and any attorney fees incurred by the parties.
Date form is completed:
_____________________
Claim #:
_______________________
(Claimant: this number will be provided upon filing the claim with the Division)
This form is being completed on behalf of: ……………………………
Claimant
Respondent
Is the above indicated party: ………………………………………...........
Unit Owner
Homeowners Association
Subsidy is based on to the unit address the claim is filed in reference to
For subsidy to be approved, for either party, the primary unit address involved in this claim is required:
Unit Owners Name: _________________________________________________________________
Unit Address: ____________________________________________________________________________
Street
City
State
Zip Code
*If the Respondent is completing this form, please list the primary unit address involved in this claim
Mailing address for the party applying for Subsidy:
Name: __________________________________________________________________________________
If party is represented by an attorney: ____________________________________________________
Please provide the name of the Law Firm and the name of the attorney
Contact Address: __________________________________________________________________________
Street
City
State
Zip Code
Contact Phone: ________________ Fax: ___________________ E-Mail:______________________________
Claimant’s acknowledgments:
_______
Initial here confirming your claim was filed within one year of discovery. *
 In order for subsidy to be approved, the claim form must be filed within 1 year from the date of discovery of the
(Initial)
issues(s) listed on claim form.
Claimant’s & Respondent’s acknowledgments:
_______
If subsidy is denied, I acknowledge I will be responsible for the cost of the Mediation.
(Initial)
_______
I acknowledge that the Subsidy Application will ONLY be accepted, and reviewed, prior to the claim being
(Initial)
assigned to a Mediator/Referee.
Yes
No
Have you received a subsidy during the State’s current fiscal year? (The State’s fiscal year is July 1 – June 30)
If yes, indicate: Claim #:_________Claimant Name: ________________ Unit Address: ________________________
Association’s acknowledgments:
Yes
No
Is the association is “Good Standing” with both the Office of the Ombudsman and Secretary of the State?
_______
If the Association is “Not in Good Standing” with either the Secretary of State and/or the Ombudsman Office,
(Initial)
I acknowledge subsidy will be denied.
FOR OFFICIAL USE ONLY - MEDIATOR
Date claim assigned to mediator: __________________
Date form received by the Division ______________________________
Date form completed and submitted to Ombudsman’s office __________________________
Date of Mediation_______________________________
Revised: 7/5/16
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