Form 521 - Respondent Form
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2STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
2501 East Sahara Avenue, Suite 202 * Las Vegas, NV 89104-4137
(702) 486-4480 * Toll free: (877) 829-9907 * Fax: (702) 486-4520
E-mail:
CICOmbudsman@red.state.nv.us
ALTERNATIVE DISPUTE RESOLUTION (ADR)
RESPONDENT FORM
Please review the ADR Overview, Form #523, prior to completing this form.
NOTE: Referee and arbitration decisions are public records and will be published on the Division’s website. Parties that participated in
a referee hearing or arbitration resulting in a decision can request, in writing, to the Division to have their identifying information
(name, address, phone number) redacted from the decision that is published.
Date: ___________________
________________________________
Signature of Respondent (or attorney)
Claim #: _________________
Located on the bottom of the Claim Form
Respondent:_________________________________________________________________
If individual, provide full name. If an Association, provide COMPLETE Association name as it appears on Secretary of State’s website. ( )
* Please list only one party; attach Additional Claimant Form (#520B) if there is more than one Respondent
If Respondent 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:_____________________________
PLEASE SELECT YOUR METHOD OF RESOLUTION:
________ MEDIATION
________ REFEREE PROGRAM *
* Please Note - If Claimant has elected to participate in the Referee Program, you must also agree; otherwise the claim will
be submitted to Mediation.
______
I have read and agree to the policies stated in the ADR Overview (Form #523).
(Initial)
______
I mailed a copy of this Respondent Form and any supporting documents to the Claimant at the
address on the Claim Form.
Date packet was mailed: _________________________________________
______
I agree to use the mediator/referee identified by the Claimant on page 3 of the Claim Form
Mediator/ Referee listed on Claim form : ______________________________
______
I disagree with the mediator/referee identified by the Claimant on page 3, therefore I agree to
have the Division assign the mediator/referee at random.
For office use only:
Receipt number: _________________________ Claim number: _______________ Date received: __________________________________
Revised: 07/6/16
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