Revised 1/11/2019 Page 1 of 2 Form 623
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS PROGRAM
3300 W. Sahara Avenue, Suite 350 * Las Vegas, NV 89102
(702) 486-4480 * Toll free: (877) 829-9907 * Fax: (702) 486-4520
E-mail: CICOmbudsman@red.nv.gov
http://red.nv.gov/
REGISTRATION FILING ADDENDUM
The Association shall submit this form to the Division within 30 days of any change in board membership or hired agents, including any
change in contact information (NAC 116.385). There are NO FEES associated with this form. Any changes submitted are for Division use
only and will not be reported to the Secretary of State. If submitted incomplete, this form will not be processed and will be returned to sender.
Association’s Legal Name _______________________________________________________________________________
(As it appears in the Articles of Incorporation/Secretary of State’s website)
Association’s Subdivision Name(s) ________________________________________________________________________
(As it appears on the County Assessor’s website)
Nevada Secretary of State (SOS) Entity Number __________________________ SOS Original File Date ____/____/____
(For SOS Filing information, visit http://nvsos.gov/sosentitysearch/)
Is the Association identified as a Master or Sub-Association, per the CC&Rs? ………….. Master Sub-Association Neither
If identified as a Sub-Association, please indicate the name of the Master Association ___________________________________________
Has there been a change in address for correspondence with the Association? Yes (complete below) No
C/O ________________________________________________________ Attn. ________________________________________________
Address_________________________________________________________ City ______________________ State ______ Zip ________
Association’s Telephone Number _____________________________________ Fax Number _____________________________________
(This phone number will be supplied to the public)
Has there been a change in Management Company? ………………….………
Yes (complete below) No
If changing management company, complete the Custodian of Record below this section as well.
Management Company Name ___________________________________________________________ Same Correspondence Address as above
Address_________________________________________________________ City ______________________ State ______ Zip ________
REQUIRED if YES for this portion: Date new Management began ………………………………………………… ______/______/______
Has there been a change in the Association’s Custodian of Records? ………….
Yes (complete below) No
Individual (not company) designated as the Custodian of Records ________________________________________________ Same as CM
List the address where the Association’s records are located below …………………………………………..
Same as Correspondence Address
Address_______________________________________________________ City ______________________ State ______ Zip __________
Telephone Number ___________________________________ Fax Number ______________________________________
Has there been a change in Community Manager (CM)? ……………………… Yes (complete below) No
If changing the community manager, complete the Custodian of Record above this section as well with current Custodian.
Name of Licensed Community Manager ________________________________________________ CM License #__________________
(As it appears on the license issued by the Real Estate Division)
Name of Management Company: ____________________________________________________________________________________
Licenses type: Temporary Certificate Provisional Designation Supervisory Designation
If CM is a Temp or Provisional, Supervising Manager _______________________________________ Sup. CM License # ______________
REQUIRED if YES for this portion: Date new Manager began ……………………………………………………… ______/______/______
Has there been a change in the Association’s Attorney of Record? …………… Yes (complete below) No
Name of Law Firm _______________________________________________ Name of Attorney __________________________________
Address _______________________________________________________ City _____________________State: ______ Zip: __________
Telephone Number ____________________________________________ Fax Number __________________________________________
FOR OFFICIAL USE ONLY
First Date Stamp: _____________________________________________ Date Processed: _________________________________ Processed By: _______________
Second Date Stamp: ___________________________________________ Date Processed: _________________________________ Processed By: _______________
Revised 1/11/2019 Page 2 of 2 Form 623
Has there been a change to the board, including officers/ contact information? Yes (complete all below) No
Per the governing documents, how many board members are required? …………………………………….…………….…… ____________
How many members are currently on the board? ………………………………………………………………………………. ____________
How many officers are not unit owners? __________, indicate office(s) held: …………………………………... Pres Sec Tres VP
ALL CURRENT BOARD MEMBERS
(The number of board members listed below must match the number listed above for How many members are currently on the board”
List all board members, including those who are newly elected, re-elected, appointed or changed officer positions since last registration or addendum)
NO LONGER SERVING ON BOARD
(List those whose terms have expired, resigned, removedsince last registration or addendum)
The person signing this form must be the Declarant, Board Member or assigned Community Manager who is attesting to the accuracy of
the information provided, regardless of whether they completed the form.
The person signing is Declarant Board Member (Position ___________) Community Manager (License # _____________)
Authorized Name ____________________________ Authorized Signature _____________________________ Date ____/____/_____
This form can only be submitted by hand delivery, mail or fax and will not be accepted by email.
Executive Board
Pres Sec Tres VP Dir Pres Sec Tres VP Dir Pres Sec Tres VP Dir
Reason
Elected Appointed Position Change Elected Appointed Position Change Elected Appointed Position Change
Board Member’s
Name
Personal Address
Number & Street
City / State / Zip
Personal Telephone
Number
Term dates
(Mo./day/yr.) / / thru
(Mo./day/yr.) / / thru
(Mo./day/yr.) / / thru
(Mo./day/yr.) / /
(Mo./day/yr.) / /
(Mo./day/yr.) / /
Executive Board
Pres Sec Tres VP Dir Pres Sec Tres VP Dir Pres Sec Tres VP Dir
Reason
Elected Appointed Position Change Elected Appointed Position Change Elected Appointed Position Change
Board Member’s
Name
Personal Address
Number & Street
City / State / Zip
Personal Telephone
Number
Term dates
(Mo./day/yr.) / / thru
(Mo./day/yr.) / / thru
(Mo./day/yr.) / / thru
(Mo./day/yr.) / /
(Mo./day/yr.) / /
(Mo./day/yr.) / /
Executive Board
Pres Sec Tres VP Dir Pres Sec Tres VP Dir Pres Sec Tres VP Dir
Reason
Term expired
Resigned
Removed
Term expired
Resigned
Removed
Term expired
Resigned
Removed
Transition from Declarant
Other:________________________
Board Member’s
Name
End Date
(Mo./day/yr.) / / (Mo./day/yr.) / / (Mo./day/yr.) / /
Executive Board
Pres Sec Tres VP Dir Pres Sec Tres VP Dir Pres Sec Tres VP Dir
Reason
Term expired
Resigned
Removed
Term expired
Resigned
Removed
Term expired
Resigned
Removed
Transition from Declarant
Other:________________________
Board Member’s
Name
End Date
(Mo./day/yr.) / / (Mo./day/yr.) / / (Mo./day/yr.) / /