Revised 4/16/2018 Page 2 of 2 Form 522
Please describe any experience with the mediation of homeowner association disputes. If no experience, please
enter N/A:
__________________________________________________________________________________________
__________________________________________________________________________________________
Geographic Service Area:
☐ Reno/Carson/Tahoe Area
☐ Northeastern Nevada
☐ Central Nevada
☐ Greater Las Vegas Area
Please list foreign languages, or sign language, in which you have sufficient fluency to serve as a neutral:
__________________________________________________________________________________________
__________________________________________________________________________________________
Fee and Expenses:
_____________ Hourly Rate: $167 per hour.
_____________ Should I be appointed to the ADR Mediation panel, I acknowledge that as per NRS 38.330(2), all
mediations are to be conducted at the maximum rate of $500 for no more than (3) hours. Any
additional mediation time must be agreed upon by all parties involved, and the rate of this additional
this is to be no more $200.00 per hour.
_________
____ I acknowledge that Mediation proceedings may be subsidized by the Division as per NAC 116.520
in an amount not to exceed $500 or $250 for each party who is eligible for subsidy, whichever is
less; and that I am not an employee of the State of Nevada, and therefore, I am eligible to receive
subsidy payments from the State.
_________
____ I CERTIFY that the above information and any other information I am submitting for this
application is true and correct to the best of my knowledge and that I may be removed from the
Mediation panel or the approved Division Neutral List for intentionally falsifying the information
provided. False certification may also subject me to civil or criminal penalties. I understand that
all of the information provided is a public record. I agree to comply with all provisions of NRS
Chapter 38.
_________
____ If I am listed on the Division Neutral List, I agree to perform resolution services to the best of my
ability in an ethical and proper manner and in accordance with the time provisions of the Mediation
process.
______________ I acknowledge that unless otherwise agreed to by the parties, the mediator is appointed on a rotating
basis within the discretion of the Division.
_________
_______________________________ __________________________________ _____________
Signature Print Name Date
ST
ATE OF ____________________________ ___ ss. COUNTY OF ___________________________________
I certify that this is a true and correct copy of a document in the possession of ________________________________
PRINT NAME
_________
________________ ______ __________________________
Notary Signature Commission Expiration:
