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 2/19/2020 Page 1 of 2 Form 521
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 Number:
Located at the bottom of the Claim Form
Respondent:
If individual, provide full name. If an Association, provide COMPLETE Association name as it appears on the Secretary of State’s website.
Please list only one party; attach Additional Claimant Form 520B if there is more than one Respondent
Law Firm and Attorney (if applicable):
Provide the name of the law firm and the name of the attorney. An attorney is not required.
Contact Address:
Street and number, city, state, and zip code
Contact Phone: Fax Number: Email Address:
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.
INITIAL
I have read and agree to the policies stated in the ADR Overview (Form #523).
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:
