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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 West Sahara Avenue, Suite 325, Las Vegas, NV 89102
(702) 486-4480 Toll free: (877) 829-9907 Fax: (702) 486-4520 * *
E-mail: CICOmbudsman@red.nv.gov http://www.red.nv.gov
INTERVENTION AFFIDAVIT (Form 530)
Statements 1 through 4 cited below must be met prior to filing this Affidavit. Please verify that you have met the
requirements by initialing in each box. As the aggrieved party, you:
1. Are filing this complaint not later than 1 year after you discovered or reasonably should have discovered the
alleged violation. Date alleged violation took place: ____________________
2. Have mailed to the Respondent’s last known address a certified letter, return receipt requested,
specifying
in reasonable detail: all alleged violations, any actual damages suffered, and any corrective actions proposed.
A copy of this letter and the certified return receipt from the post office must be attached to this form.
Any and
all allegations included in the certified letter must also be included on this form. Any allegation not
indicated
will not be considered by the Division.
3. Have provided the Respondent with at least 10 business days to correct the alleged violation(s) pursuant to the
governing documents or NRS and NAC 116. All other reasonable efforts to resolve the allegation(s) must
have failed prior to filing this Intervention Affidavit.
4. Have stated only one alleged violation per page and have included applicable attachments (Exhibits) behind
each such page. It is advised that you make a copy of this package for yourself prior to submission.
Please indicate whether you have spoken to a staff representative from the Ombudsman’s Office to understand
which specific provision of NRS or NAC 116 may have been violated.
Yes ☐ No ☐ If yes, name: _________________________
STATE OF NEVADA
COUNTY OF:
________________ __________________
_________________________
DATE:
I, , (Complainant), after being first duly sworn, state under penalty of perjury
and based upon personal knowledge have been aggrieved by an alleged violation of Chapter 116 of the
Nevada Revised Statutes, Nevada Administrative Code or the governing documents of the association.
1. The person or entity who committed the alleged violation and who was sent the required certified letter is (if
multiple, list each Respondent):
2. The Respondent
or respondents
role in the community:
3. The Homeowners Association involved in this Intervention Affidavit is:
4. List the Association’s
Secretary of State (SOS) Business ID Number _______________________________
To
locate SOS ID
Number go to the
Secretary of State website.
Revised 5/1/2019
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Form 530
