Form 521 - Respondent Form Page 2
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2PROVIDE A BRIEF STATEMENT PERTAINING TO THE NATURE OF THE DISPUTE
“SEE ATTACHMENT” IS NOT ACCEPTABLE. Your explanation must start on this page. You may attach
additional pages, if more space is needed.
In order for the claim to be considered filed, the following must be submitted, if applicable.
Please indicate by initial that the following steps have been completed:
__
Forms:
(Initial)
One (1) Original Response Form, # 521
One (1) copy of the Response Form and supporting documents
Supporting documents may be provided directly to the mediator or referee once assigned
and need not be provided with this Claim Form.
Should you chose to submit your
documents; you must supply one (1) original set of One (1) copies.
__
Filing Fee of $50.00 payable to “NRED” in the form of (This fee is nonrefundable):
(Initial)
Money (exact change; Please do not mail cash)
Money Order
Check
I acknowledge that the Subsidy Application will ONLY be accepted, and reviewed,
________
prior to the claim being assigned to a Mediator/Referee.
(Initial)
__
ADR Subsidy Application for Mediation (Form #668):
Subsidy is awarded based on:
(Initial if applicable)
For a Unit Owner:
Once during each fiscal year of the State for each unit owned
For an Association
Once during each fiscal year of the State against the same unit owner for each unit
owned
In “Good Standing” with Secretary of State & Office of the Ombudsman Office
Should you be awarded subsidy, the Division will notify you via your opening letter.
__
I acknowledge that the Respondent will
be applying for Subsidy for this claim.
NOT
(Initial if applicable)
Once the Division processes your Respondent Form, the Division will assign a mediator
or a referee, based on the information supplied in this form.
Once a mediator or referee has been assigned, all communications are to be directed to
the assigned individual.
Revised: 07/6/16
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