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REAL ESTATE DIVISION NEVADA STATEMENT OF RECORD (Nevada Real Estate Division)

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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
e-mail: realest@red.nv.gov * http://red.nv.gov/
Revised: 03/20/17 Page 1 of 29 563
NEVADA STATEMENT OF RECORD
This is a companion document to the "Property Report," Document 564.
This form must be filed for any division of land into 35 or more lots, parcels, units or interests being offered for sale
or lease in a common promotional plan, including subdivisions permitted by H.U.D. If the property filed in this
statement has been permitted by H.U.D., then attach H.U.D. effective date letter.
The fees for filing this Registration are based on the following schedule:
Preliminary Permit $275.00
Permit including 50 interests $500.00
#51 - #250 Interests $ 5.00 each
#251 - #500 “ $ 4.00 each
#501 - #750 “ $ 3.00 each
#751 - #1500 “ $ 2.50 each
#1501 - and over $ 1.00 each
Annual Renewal $500.00
Amendment $150.00
Attach the required filing fees at the time of filing. Examination of the filing will not begin until all required filing
fees are received.
UNLESS OTHERWISE DETERMINED BY THE DIVISION, ALL FEES SUBMITTED PURSUANT TO NRS
119.320 ARE DEEMED EARNED UPON RECEIPT. NOT MORE THAN ONE-HALF OF THE FEE
SUBMITTED SHALL BE SUBJECT TO REFUND. REFUNDS CAN ONLY BE MADE IN THE FISCAL YEAR
IN WHICH THE FEES ARE DEPOSITED.
At the time an inspection is scheduled, a deposit of inspection fees will be requested.
DO NOT SEND INSPECTION FEES WITH THIS FILING.
The estimated inspection fees for this Registration will be based on the following schedule:
In-State Property $300.00
Out-of State Property (up to 1000 miles) $500.00
Out-of State Property (in excess of 1000 miles) $850.00
These inspection fees are estimated expenses only. Any additional expenses over and above this estimate will be billed
after the actual inspection. Any actual costs incurred less than the estimated amount will be refunded.
No permit or Property Report will be issued by the Division until all material required by the Division has been supplied,
the subdivision has been inspected by the Division and all fees paid, including inspection fees as may be required by the
Division.
This statement and, if necessary, the Property Report, must be continually kept up to date throughout the sales
program. Any material changes to the Statement must be communicated to the Division within fifteen (15) days of its
occurrence. Failure to do so may render the Property Report invalid, which means all purchasers purchasing subject
to an invalid Property Report may have the opportunity to void their contract and receive back all the funds paid to
date.
Revised: 03/20/17 Page 2 of 29 563
For each amendment to a developer’s permit after the issuance of the report there will be a $100 fee.
THE PERMIT ISSUED PURSUANT TO CHAPTER 119 NEVADA REVISED STATUES EXPIRES ONE YEAR
FROM THE DATE OF ISSUANCE AND MUST BE RENEWED.
These instructions must be followed in completing the Questionnaire and Exhibits Sections. PLEASE READ THESE
INSTRUCTIONS CAREFULLY.
The format must not be changed in any respect, except as follows:
1. Answer the questions in the spaces provided in this Statement. If additional space is needed, attach
separate sheets by placing on them the number and letter of the question being answered.
Deeds, title policies, maps, plats and other supporting documents should be folded to legal size. Do
not submit photocopies which are not clearly readable.
2. The supporting documents required under Section II Exhibits shall be attached as exhibits. Each
exhibit shall be identified by affixing a tab on the right side of the cover sheet of the exhibit. Such
identification shall conform to the alphabetical format of Section II. Each exhibit shall be numbered
sequentially beginning with the number of the Section followed by the Exhibit letter- Example:
Exhibit 11-A, II-Q-4, etc. Additionally or supplementary exhibit material shall be identified and
numbered following the same system.
3. There shall be an “Index to Exhibits.” Such Index schedule shall be the cover page of Section II
Exhibits.
4. If the information in an exhibit is applicable to more than one part of the Questionnaire, the
developer may incorporate that information by reference to the appropriate exhibit.
5. Where items in the Questionnaire do not apply, so state by stating “Not Applicable” in answer
thereto and BRIEFLY EXPLAIN WHY.
6. Where documentation required in the Exhibit Section does not apply, in lieu of an exhibit, the
applicant shall insert a page reciting the exhibit identification and description as set forth and
indicate thereon “Not Applicable” and BRIEFLY EXPLAIN WHY.
7. Where required documentation cannot be obtained, a page shall be inserted indicating “Not
Available” and BRIEFLY EXPLAIN WHY.
8. Do not incorporate by reference to a previous filing the answers to questions in Section I. The
applicant may incorporate specifically by reference documentation required in Section II Exhibits
from a previous filing with the Division. The applicant must state exactly where the documentation
can be found, e.g., subdivision name and previous exhibit number.
9. After completing this Statement of Record and the exhibits section, please bind them at the top with
a fastener.
When this Statement has been completed, complete the enclosed Property Report. The answers to the questions in the
Property Report are based upon your information in this Statement.
BUSINESS AND INDUSTRY NEVADA REAL ESTATE DIVISION
Revised: 03/20/17 Page 3 of 29 563
SECTION I
STATEMENT OF RECORD (Questionnaire/Application)
Date:
1.
Applicant
a.
b.
c.
d.
e.
f.
(1)
Been convicted of or pled nolo contendere to a felony or other crime involving moral turpitude,
fraud or misrepresentation, land sales or investments, securities sales, campgrounds, timeshares
Yes No
(2)
Been permanently enjoined by a court of competent jurisdiction from selling real estate,
timeshares, campgrounds, securities Yes No
(3)
Had a registration as a broker-dealer in securities or a license to act as a real estate broker or
salesman, project broker or sales agent revoked Yes No
(4)
Been convicted of or pled nolo contendere to selling real estate, investments, securities,
timeshares or campgrounds without a license Yes No
(5)
Had a permit to sell timeshares, securities, real estate or campgrounds revoked
Yes No
(6)
Been disciplined, disbarred, or suspended by any governmental body or agency for violation of
any federal, state or local law or regulation in connection with activities relating to land sales,
land investments, securities sales, construction or sale of homes or home improvements,
campgrounds, timesharing or other similar activity. If so, describe the action. Include in your
description the names and addresses of the parties involved, the type and date of the action, and
the status and disposition thereof Yes No
Revised: 03/20/17 Page 4 of 29 563
g.
h.
i.
2.
Subdivision
a.
b.
c.
d.
e.
Number of lots, units or interests in this filing:
f.
Smallest lot or unit (square feet):
g.
Minimum road footage:
h.
Gross acreage in entire subdivision:
i.
Gross acreage in this filing:
Revised: 03/20/17 Page 5 of 29 563
3.
Location
a.
b.
c.
Name of Community
Population
Distance Over
Paved Roads
Total
d.
4.
Platting
a.
b.
c.
d.
Revised: 03/20/17 Page 6 of 29 563
5.
Geology, Climate and Physical Conditions
a.
b.
c.
d.
e.
f.
Revised: 03/20/17 Page 7 of 29 563
g.
h.
6.
Taxes, Assessments
a.
b.
Date next payment due:
c.
d.
e.
f.
g.
Revised: 03/20/17 Page 8 of 29 563
h.
i.
7.
Type of offering in this filing. If subdivision is a condominium project disregard items a-d and so state.
a.
b.
c.
Revised: 03/20/17 Page 9 of 29 563
d.
e.
f.
g.
h.
8.
Improvements
a.
Description
When completed
Cost, if
available
Graded Roads
Paved Roads
Electrical Supply
Central Water
Sanitary Sewers
Drainage
Curbs and Gutters
Revised: 03/20/17 Page 10 of 29 563
Sidewalks
Street Lighting
Gas Supply
Telephone Service
Dwellings
c.
d.
e.
f.
Revised: 03/20/17 Page 11 of 29 563
g.
(1)
Does each purchaser have legal access to the subdivision and within the subdivision to each lot
or unit? Yes No Please explain.
(2)
Does each purchaser have physical access (by conventional automobile, year-round) to the
subdivision and within the subdivision to each lot or unit? Yes No Please
explain.
(3)
Who will maintain the access roads to the subdivision and within the subdivision to each lot or
unit? Please explain. (State who will maintain the access roads. If the cost of maintenance
will be borne by the purchaser or any association of purchasers, so state and give the estimated
cost to each purchaser).
(4)
Who will clear the roads of snow? (State who will clear the roads of snow. If the cost of snow
removal will be borne by the purchaser or any association of purchasers, so state and give the
estimated cost to each purchaser).
h.
1)
If subdivision is a condominium project disregard items 2-4 and provide here the name of the
supplier, any required deposits and/or hookup charges and monthly rate.
Revised: 03/20/17 Page 12 of 29 563
(2)
If electricity is not promised or completed, is it available? Yes No If yes, give
name and address of electric company and how it can be made available.
(3)
Does the developer or any associate own the electric company? Yes No If yes,
give full disclosure.
(4)
Disclose costs for electricity to the purchaser including the amount of the normal hookup
charge and current rates.
i.
(1)
If subdivision is a condominium project disregard items 2-6 and provide here the name of the
supplier, any required deposits and/or hookup charges and monthly rate.
(2)
Will the water supply be adequate to serve the anticipated population of the area?
Yes No
(3)
What type of system will supply water? Community supply Individual wells
(4)
If community system, who owns the system?
(5)
If the supplier is an associate of the developer, please explain.
Revised: 03/20/17 Page 13 of 29 563
6)
Disclose all costs for water to the purchaser, including the amount of the normal hookup
charge and rates.
j.
(1)
If subdivision is a condominium project disregard items 2-4 and provide here the name of the
supplier, any required deposits and/or hookup charges and monthly rate.
(2)
What type of sewage disposal system will be available within the area described in this filing?
Community sewage system Individual system
(3)
If community system, who owns the system?
(4)
Disclose all costs for sewer or individual system, to the purchaser including the amount of the
normal hookup charge and rates or cost of installing an individual septic system.
k.
(1)
If subdivision is a condominium project disregard items 2-3 and provide here the name of the
supplier, any required deposits and/or hookup charges and monthly rate.
(2)
If telephone service is not promised or completed, is it available? Yes No If
yes, give name and address of telephone company and how it can be made available.
Revised: 03/20/17 Page 14 of 29 563
(3)
Disclose all costs for telephone service to the purchaser including the amount of the normal
hookup charge and rates.
l.
(1)
If subdivision is a condominium project disregard items 2-3 and provide here the name of the
supplier, any required deposits and/or hookup charges and monthly rate.
(2)
Which of the following is available? Natural Gas Fuel Oil Bottled Gas
(3)
Disclose all costs to be incurred by a purchaser for hookup, tank, operating and rates.
(4)
Does the developer or any associate own the fuel company? Yes No If yes,
explain fully.
9.
Area Facilities and Services
a.
b.
c.
Revised: 03/20/17 Page 15 of 29 563
d.
e.
f.
g.
h.
i.
j.
k.
l.
Revised: 03/20/17 Page 16 of 29 563
10.
Recreational and Common Facilities
a.
b.
c.
d.
11.
Filings with State/Federal/Provincial Authorities. If a property registration has been filed with or accepted
by any regulatory agency, list the jurisdictions:
12.
Terms and Conditions of Sale.
a.
b.
Revised: 03/20/17 Page 17 of 29 563
c.
d.
e.
f.
g.
h.
i.
Minimum down payment on installment sales:
j.
Maximum term of installment contracts
k.
Annual interest rate
Revised: 03/20/17 Page 18 of 29 563
l.
m.
n.
o.
p.
q.
r.
s.
t.
Sales prices range from $
to $
Revised: 03/20/17 Page 19 of 29 563
u.
v.
w.
13.
Title
a.
b.
c.
All sums paid or advanced by purchasers will be placed in an escrow or other depository
acceptable to the Division until the fee title contracted for is delivered to such purchaser by
deed together with release from all financial encumbrances.
The fee title to the subdivision will be placed in trust under an agreement or trust acceptable to
the Division until a partial release from each blanket encumbrance including all taxes is
obtained and title contracted for is delivered to the purchaser.
Such blanket encumbrance contains provisions evidencing the subordination or release of the
lien of the holder or holders of the blanket encumbrance to the rights of those persons
purchasing from the developer and further evidencing that the developer is able to secure
releases from such blanket encumbrance with respect to the property upon full payment of the
purchase price owed by such person.
Revised: 03/20/17 Page 20 of 29 563
d.
e.
14.
Promotional Activities
a.
(1)
The form and content of advertising to be used;
(2)
If there are any inducements such as gifts, free offers or any other promises offered to
prospective purchasers, explain: (Disclose fully all information regarding inducements
including, but not limited to, the following: gifts, free offers, resale or lease program, exchange
privilege, inspection privilege, sweepstakes, or drawings.)
(3)
The nature and content of promotional meetings.
b.
Revised: 03/20/17 Page 21 of 29 563
c.
15.
Fully disclose any information about the subdivision or the sales methods which the Nevada Statement of
Record failed to ask for. If there is no other information, then so state.
Revised: 03/20/17 Page 22 of 29 563
SECTION II
EXHIBITS
Exhibit A
If a corporation, submit a copy of Articles of Incorporation with all amendments thereto and a
current list of all the names and addresses of officers and directors with their principal
occupation for the past 5 years. Submit name and address of any person whose interest in the
applicant is 10% or more and the extent and nature of such ownership.
Exhibit B
If the developer is a foreign corporation and is organized under the laws of another state,it may
be necessary to register with the Nevada Secretary of State as a foreign corporation doing
business in the State of Nevada. The developer should contact the Secretary of State to
ascertain whether registration is necessary. If registration is not necessary, submit a current list
of officers and a statement from the corporate regulatory agency that the corporation is in good
standing.
Exhibit C
If the developer is a Nevada corporation, submit a copy of the current list of officers filed with the
Nevada Secretary of State, indicating the corporation’s resident agent
Exhibit D
Submit a diagram indicating the position of the developer in relation to any subsidiaries and parent
corporation.
Exhibit E
If a partnership or association, submit a copy of the Declaration of Partnership or Association or
other organizational documents.
Exhibit F
Consent to Service of Process
File an irrevocable consent for service of process with the Nevada Secretary of State from the
developer and from each individual or entity owning or controlling a 10% or more interest in the
developer. Your filing will be considered incomplete without the consent(s). SEND THE
ATTACHED CONSENT FOR SERVICE OF PROCESS FORM DIRECTLY TO THE NEVADA
SECRETARY OF STATE WITH A CHECK IN THE AMOUNT OF $10.00 TO COVER FILING
FEES. If additional forms are needed, please duplicate the attached form.
Exhibit G
Copy of financial statement.
Submit a copy of the financial statement(s) of the developer. Such financial statement(s) shall not
be more than 6 months old and shall include a balance sheet and statement of profit and loss. They
shall be prepared by an independent certified public accountant.
Exhibit H
Submit a copy of the documents involved in the litigation or other action listed in Section I, l,f,g,h,
if any. This includes but is not limited to copies of the following:
1. All Pleadings
2. Decision or other disposition
Exhibit I
A general location map showing total property offered or to be offered, drawn to scale,
indicating property included in this filing and property previously registered, if any, in Nevada.
Exhibit J
Copy of recorded plat map showing provisions for legal access to all lots or units included in
this Statement.
Revised: 03/20/17 Page 23 of 29 563
Exhibit K
Submit a statement from the city and/or county assessor’s office showing the tax rate per $100
of assessed valuation, the highest and lowest assessed valuation for individual lots or units, the
highest and lowest market value, and the fiscal year for which it applies, covering the property
included in this filing. If the property is located outside the State of Nevada, please submit a
letter from the assessor showing the estimated taxes and the information upon which it is
based.
Exhibit L
Submit evidence from appropriate government authority or other verification that the uses for
the lots or units being offered are not prohibited by local zoning.
Exhibit M
Improvements and Facilities:
1. If the subdivision is or will be a completed condominium, submit a copy of the certificate
of occupancy and disregard items 2-13
2. Copy of the construction schedule for all promised improvements.
3. Copy of contracts with public utilities for the installation of any improvements completed
or promised. (Electricity, telephones, etc.)
4. Copy of Engineer’s Statement as to estimated costs of any promised improvements not
completed.
5. Submit a copy of the County’s Subdivision Improvement Agreement.
6. Copy of performance bonds or agreements assuring the completion of promised
improvements.
7. Copy of documents or letter showing what government entity has agreed to accept
maintenance of the roads and drainage, if applicable.
8. Copy of a licensed engineer’s cost estimate to survey any given lot in the filing. (This
exhibit applies only if section I,8,c is answered in the negative)..
9. If the answer to Section I,8,i(2) was yes, submit documentation from the State agency
vested with that authority
10. If the water system is complete, submit verification from the proper public authority that
such a system is complete and accepted.
11. If individual wells on each lot will be necessary for a water supply, submit a licensed well
driller’s estimated cost for drilling and casing a well, estimated cost of pump and pressure
system installed and the depth at which potable water may be found.
12. If privately supplied water or individual wells are to be the source of water for human
use, provide documentation that the state or county health authority issued a report on the
quality of the water.
13. Submit confirmation from the local or state health authority that individual wells will be
permitted considering the size of lot proposed and the type of sewage systems to be
utilized based on the smallest lot contained in this filing.
Exhibit N
Submit a copy of the recorded Covenants, Conditions and Restrictions and a copy of any
easements that burden the property.
Revised: 03/20/17 Page 24 of 29 563
Exhibit O
If an association exists or is to be formed, submit the articles of incorporation and bylaws of
the association together with a financial statement and proforma budget.
If monies paid by buyers or lessees as assessments, dues or other payments for the purpose of
providing any services or maintenance on any lots, units or common facilities or areas are
received by the developer or any other organization or entity other than property owners
association, a statement of sources and application of funds, received for such purposes shall
be submitted.
Exhibit P
Evidence of Title:
1. Submit preliminary title report or equivalent document suitable to the Division, issued
after final unit maps are recorded and the title report shall not be dated earlier than 20
business days prior to the filing of this Statement.
2. Copies of existing deeds of trust or mortgage(s).
3. Copy of any other encumbrances. (This is to include all community and recreational
facilities.)
Exhibit Q
Copy of conveyances bearing recordation data by which the owner acquired title to the property
in this filing.
Exhibit R
Copy of escrow instructions, trust, subordination or release clauses to be used in the sale of the
subdivision providing protection of the purchaser from creditors of the developer as required
by NRS 119.230.
Exhibit S
If your answer to Section I,7,d was answered in the affirmative, submit a legal opinion
prepared by a lawyer licensed in the subdivision situs state supporting the answer.
Exhibit T
If fire protection is to be available, submit a letter from the fire protection agency stating that
protection will be provided, including any charges or special conditions.
Exhibit U
Submit a letter from the appropriate school district authority confirming the units contained in
this filing will be served by said districts or district describing the types of schools available,
i.e., elementary, jr. high, senior high, colleges, etc. The submittal from the school district
officials should also indicate whether school bus service is or will be available with or without
cost to the student and if there is a cost, how much it is.
Exhibit V
If police protection is to be available, submit a letter from the police protection agency stating
that protection will be provided, including any charges or special conditions.
Exhibit W
Sales Documents
1. Specimen copy of all sales contracts, agreements, option forms, escrow instructions to be
used in the sales program.
2. Specimen copy of lease forms.
3. Specimen copy of form of deeds, notes, deeds of trust to be used to convey property.
Revised: 03/20/17 Page 25 of 29 563
The following language must be printed clearly and conspicuously in 12-point boldface type at the
top of all contracts for the sale of land:
This is a binding contract by which you agree to purchase an interest in real
property. You should examine your rights of revocation contained elsewhere in this
contract.
The following words must be printed clearly and conspicuously immediately above the purchaser’s
signature line in each contract for the sale of real property:
The purchaser of any subdivision or any lot, parcel, unit or interest in any
subdivision not exempted pursuant to the provisions of NRS 119.120 or 119.122
may cancel the contract of sale, by written notice, until midnight of the fifth
calendar day following the date of execution of the contract, unless the contract
prescribes a longer period for cancellation. The right of cancellation may not be
waived. Any attempt by the developer to obtain such a waiver results in a contract
which is voidable by the purchaser.
The notice of cancellation must be delivered personally to the developer or sent by
certified mail or telegraph to the business address of the developer.
The developer shall, within 15 days after receipt of the notice of cancellation,
return all payments made by the purchaser.
Every contract of sale of subdivision property located outside Nevada which is sold within this
state must contain one of the following sentences:
This contract is to be construed according to the laws of the State of Nevada and
specifically chapter 119 of NRS, or
This contract is to be construed according to the laws of , Any
purchaser solicited in the State of Nevada retains those rights granted him under
chapter 119 of NRS.
The following language or language of similar import MAY NOT be used in a contract of sale of a
subdivision or lot, parcel, unit or interest in a subdivision:
Purchaser agrees that no representations, oral or implied, have been made to
purchaser other than what is contained in this contract.
Exhibit X
Submit all advertising, promotional or sales material, whether oral, photographic, electronic or
printed, for approval, prior to its use in a sales operation. The owner’s and/or developer’s name
and connection with the sales operation must be prominently shown on all advertising. A number
will be provided by the Division for each piece of advertising material that is approved which must
be printed on all written and film material.
Exhibit Y
See attached statement to be completed and signed by the Broker of Record.
Exhibit Z
See attached Affidavit of Registrant to be completed and signed by the applicant.
Exhibit F
Revised: 03/20/17 Page 26 of 29 563
CONSENT TO SERVICE OF PROCESS
(APPLICANT: MAIL THIS FORM DIRECTLY TO THE NEVADA
SECRETARY OF STATE FOR FILING)
SECRETARY OF STATE
101 N Carson St. Ste 3
Carson City, NV 89701-4786
STATE OF
ss.
COUNTY OF
KNOW ALL MEN BY THESE PRESENTS:
that pursuant to the provisions of Nevada Revised Statutes 119
hereinafter referred to as “Developer,” hereby
irrevocably constitutes and appoints the Secretary of State of the State of Nevada or his successor in office, to
be its true and lawful attorney within this state, upon whom all legal process in any suit, action or proceeding
arising under, or in any way connected with the violation of any provision of Nevada Revised Statutes 119 or
any rule or order pursuant thereto, or based upon any fraud, deceit, breach of contract or other thing connected
with the sale or offer for sale of subdivision property, may be served with the same force and validity as if in
fact served upon said applicant, personally, within the State of Nevada. This appointment and the authority of
said attorney shall continue in force and effect so long as any such liability remains outstanding, and a copy of
any process served hereunder may be sent by registered mail addressed to:
Street Address
City
State
Zip
STATE OF
ss.
COUNTY OF
IN WITNESS WHEREOF, the aforesaid developer has caused these presents to be executed this
day of
20
CORPORATE SEAL
(If corporation)
Developer
BY
Attest:
Signature
Secretary
Title
Revised: 03/20/17 Page 27 of 29 563
FOR
CORPORATION
Before me, a Notary Public, in and for said county and state, personally appeared
and
to me
known to be the persons who executed the foregoing instrument, who being first duly sworn,
severally made oaths that they are the president and secretary, respectively, of said corporation;
that the seal affixed hereto is the seal of said corporation, and that said instrument was signed,
sealed and delivered in behalf of said corporation by authority of its board of directors as its free
and voluntary act for the use and purposes therein set forth.
WITNESS my hand and official seal this
day of
20
My Commission expires:
(SEAL)
Notary Public
FOR PARTNERSHIP
OR TRUST
Before me, a Notary Public, in and for said county and state, personally appeared
to me known
to be the person who executed the foregoing instrument, who, being first duly sworn, upon
oath deposes and says that he is a (partner) (trustee) of said (partnership) (trust), that said
instrument was signed, sealed and delivered for and on behalf of said (partnership) (trust) and
with authority of its (partners) (trustees) as its free and voluntary act for the use and purposes
therein set forth.
WITNESS my hand and official seal this
day of
20
My Commission expires:
(SEAL)
Notary Public
FOR
INDIVIDUAL
Before me, a Notary Public, in and for said county and state, personally appeared
to me known
to be the person who executed the foregoing instrument, who, being by me first duly sworn,
acknowledged under oath that he executed the said instrument as his free and voluntary act for
the use and purposes therein set forth.
WITNESS my hand and official seal this
day of
20
My Commission expires:
(SEAL)
Notary Public
Exhibit Y
Revised: 03/20/17 Page 28 of 29 563
STATEMENT OF BROKER OF RECORD
I,
a licensed real estate broker in the
State of Nevada, accept the responsibility of Broker of Record for the developer:
I am responsible for the sales activities of the licensed salesman and the promoting activities of the registered
representatives as outlined in NRS 119 and NRS 645.
I further state that:
1. I have reviewed the filing for the above named project.
2. I have personally inspected the subject property.
3. I have completely read Chapter 119 NRS and the regulations.
4. I am aware that it is my responsibility to see that the sales operation will be in complete
compliance with NRS 119 and NRS 645 and all regulations promulgated thereunder.
5. Attached is my outline for the sales operation.
6. I understand it is my obligation to notify the Division, in writing, if I terminate my relationship
with this project, employ or terminate licensed salesmen or registered representatives, or of any
change in location of offering sites within Nevada.
7. List below all offering sites within Nevada. If none, please indicate.
Project Name
Nevada Sales Site Location(s)
(Please give complete address)
Responsible Broker of Record/Branch Manager
Broker of Record Name (Print)
License Number
Telephone
Signature of Broker of Record
Dat
e
:
Firm Name of Broker of Record
Address
Subscribed and sworn to before me this
day of
20
My Commission expires:
Notary Public
Exhibit F
Revised: 03/20/17 Page 29 of 29 563
AFFIDAVIT OF REGISTRANT
STATE OF
ss.
COUNTY OF
RE:
Project
I hereby certify under penalty of perjury that the statements contained in this form constitute any notice of
intention to sell or lease subdivided lands, and that the statements together with any documents submitted
herewith are full, true, complete and correct; and that I am the owner of the parcels or units herein described or
will be at the time lots, parcels, units or interests, improved or otherwise, are offered for sale or lease to the
general public.
I further affirm and swear that I will not, over any period of time or by any means, resubdivide any of the herein
stated parcels or interests, will not dispose of or offer to dispose of subdivided lands not contained in or described
by the attached Property Registration Statement, except for previously approved subdivided land, without first
complying with the provisions of Chapter 119, Nevada Revised Statutes, and that I will notify the Division of
Real Estate within fifteen (15) days of any material change to the information in this Property Registration
Statement.
I hereby represent that as the owner of the above mentioned project, I will not place, or allow to be placed, any
mortgages or any other liens on the said real estate, other than those already in existence as of this date, copies of
which have been furnished to the Nevada Division of Real Estate as a part of the Property Registration Statement
for the aforesaid project, unless said Division is notified of this encumbrance.
I am duly authorized to prepare and am the person responsible for the content of the accompanying Property
Registration Statement.
Date
Signature
Subscribed and sworn to before me this
day of
20
My Commission expires:
Notary Public
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REAL ESTATE DIVISION NEVADA STATEMENT OF RECORD (Nevada Real Estate Division)

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Completed 28 December 2021

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