Form 668 - Application For Mediation Page 2
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1
2STATE 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
LINE ITEM INSTRUCTION SHEET
Insert the Claim Number, if available.
Indicate date application was completed.
The applicant is either a Claimant, the party filing the ADR claim, or the Respondent, the party responding to an ADR
claim.
The applicant is either the homeowner (unit owner) or the Homeowners’ Association (HOA) submitting an ADR claim. If
more
than one homeowner is a party to the ADR claim, please only indicate the one claimant who will be designated as the
primary claimant.
General information should include the association’s name or individual’s name, complete physical address, complete
mailing address, and telephone number.
In the column below the heading “HOA”, include the name of the HOA, the President’s name, and the mailing address and
telephone number of the HOA.
In the column below the heading “CAM” (Community Association Manager), include the name of the CAM organization,
the manager’s name, and the mailing address and telephone number of the CAM organization.
An attorney does not need to be retained to file a claim. If an attorney is listed on the claim, all correspondence and
any future correspondence will be sent to the Attorney of record. In the column below the heading “Attorney”, include the
firm’s name, the Attorney’s name, and the mailing address and telephone number of the Attorney.
The state’s fiscal year is from July 1 through June 30. Indicate if you received a subsidy during the State’s current fiscal
year and if so, when and for what case number.
Initial that you acknowledge you will be responsible for the cost of the Mediation if subsidy is denied.
If you are an association, indicate if you are in good standing with the Office of the Ombudsman and the Secretary of State.
Initial confirming your claim was filed within one (1) year of discovery.
FOR OFFICIAL USE – OMBUDSMAN OFFICE
CLAIM # (Year-Sequence): ____________________
Initials and Date Application Received: __________
____/____/____
Initials and Date ADR Claim Reviewed: __________
____/____/____
Initials and Date Subsidy Application for Mediation: __________
____/____/____
SUBSIDY AVAILABLE:
□ Yes □ No
□ Yes □ No
UNIT OWNER:
ASSOCIATION:
Previously subsidized in current fiscal year: □ Yes □ No
Registered, and in Good Standing, with the Ombudsman’s
□ Yes □ No
If yes, date of last subsidy:
_____/_____/____
Office and Secretary of State
Previously subsidized in current fiscal year: □ Yes □ No
If yes, date of last subsidy:
_____/_____/_____
ADR SUBSIDY APPROVED: □ Yes □ No
AAIII Initial:________
If no, indicate reason denied:
__________________________________________________________________________________________________________
AMOUNT AUTHORIZED: $________________ (Not to exceed $250)
_____________________________________________
_________________________________________
(Signature of Ombudsman)
(Date)
Revised: 7/5/16
Page 2 of 2
668
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