Purpose of the Form 

The purpose of the Disclosure of Ownership Form is to gather ownership information pertaining to a business entity when Clark County sells, leases, transfers or conveys land to, or exchanges land with, a domestic or foreign limited liability company, in compliance with Nevada Revised Statute 237.023, to be made available for public inspection upon request. 

General Instructions 

Completion and submission of this Form is a requirement of approval of a sale, lease and/or release, transfer or other conveyance, including a land exchange, (collectively “Agreement”) of land between the disclosing entity and the appropriate Clark County government entity. Failure to submit the requested information may result in a refusal by Clark County to enter into an Agreement and/or conveyance of land in any manner to such disclosing entity. 

Detailed Instructions

Business Entity Type – Domestic or foreign Limited Liability Company.
Business Name (include d.b.a., if applicable) – Enter the legal name of the business entity and enter the “Doing Business As” (d.b.a.) name, if applicable.

Corporate/Business Address, Business Telephone, Business Fax, and Email – Enter the street address, telephone and fax numbers, and email of the named business entity.

List of Owners/Officers – Include the full name, title and percentage of ownership of each person who has an ownership interest of 1% or more in the business entity.  

Signature and Print Name – Requires signature of an authorized representative and the date signed. 


Corporate/Business Entity Name:________________________________
(Include d.b.a., if applicable): ___________________________________
Street Address: _____________________________________________
City, State and Zip Code:______________________________________
POC Name:________________________________________________
Telephone No:______________________________________________
Fax No:____________________________________________________

Limited Liability Companies must list the names of individuals holding one percent (1%) or more ownership interest in the business entity. 

Full Name                                                       Title                                         % Owned

_______________________       _______________________        _____________

_______________________       _______________________        _____________

_______________________       _______________________        _____________

_______________________       _______________________        _____________

_______________________       _______________________        _____________

_______________________       _______________________        _____________

I certify under penalty of perjury, that all of the information provided herein is current, complete, and accurate. I also understand that the Board of County Commissioners will not take action on approvals, land sales, leases, transfers or conveyances, and exchanges without the completed disclosure form. 

______________________________      __________________________________
                 Signature                                                      Print Name

______________________________      __________________________________
                  Title                                                                Date

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