STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 West Sahara Avenue, Suite 350 * Las Vegas, NV 89102
(702) 486-4480 * Toll free: (877) 829-9907 * Fax: (702) 486-4520
CICOmbudsman@red.nv.gov http://www.red.nv.gov
Revised 5/1/2020 Page 1 of 1 Form 668
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 Number:
This form is being completed on behalf of Claimant Respondent
The above-indicated party is Unit Owner Homeowners Association
Subsidy is based on 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 Owner’s Name:
Unit Address:
*If the Respondent is completing this form, please list the primary unit address involved in this claim.
Contact Information for the Party Applying for Subsidy:
Name:
Law Firm and Attorney Name (if applicable):
Contact Address:
Contact Phone: Fax Number: Email Address:
Claimant’s Acknowledgements:
Initial here confirming your claim was filed within one year of discovery.
For subsidy to be approved, the claim form must be filed within 1 year from the date of discovery of the issue(s)
listed on the claim form.
Claimant’s and Respondent’s Acknowledgments:
If subsidy is denied, I acknowledge I will be responsible for the cost of the Mediation.
I acknowledge that the Subsidy application will ONLY be accepted and reviewed prior to the claim being
assigned to a Mediator/Referee.
Yes No Have you received a subsidy during the State’s current fiscal year? (The fiscal year is July 1 – June 30)
If yes, indicate: Claim Number: Claimant Name: Unit Address:
Association’s Acknowledgments:
Yes No Is the association in “Good Standing” with both the Office of the Ombudsman and the Secretary of State?
If the association is “Not in Good Standing” with the Office of the Ombudsman and/or the Secretary of
State, I acknowledge the subsidy will be denied.
FOR DIVISION USE ONLY – MEDIATOR
Date claim assigned to mediator: Date form received by Division:
