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SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVER COUNTY VALUE ADJUSTMENT BOARD <br />(APPLICANTS .MUST MEET QUALIFICATIONS OUTLINED [N FLA. STAT. $ 194.035) <br />3. Have you ever been disbarred, suspended or received any other disciplinary action from any organized <br />association, or from the State of Florida? E No ❑ Yes (please explain) <br />4.. List any personal or business relationship you have ever had with any officer or employee of the office of the <br />pr opeity appraiser, office of the clerk of the circuit court, office of the county attorney or the value adjustment <br />board of any of the counties to which you: are applying: <br />Applied for homestead exemption In the property appraisers office in 2015. 1 currently serve as chair to the CAC for the Indian River County <br />5. List any clubs; organizations, associations, or other entities to which you belong or participate in and in which a <br />possible conflict of interest could occur or the appearance of a conflict of interest might arise that would prevent <br />you from fairly conducting the hearing between the property appraiser and the property owner and taxpayer. <br />don't belong to any club or organization that would prevent me from fairly conducting a hearing. t do belong to the Garden Club of <br />Indian River County and the Vera Beach Country Club. <br />1 <br />r <br />Pursuant to Fla. Stat. 5 144.035, a person cannot serve as a special magistrate if he/she is an elected or appointed <br />official of a county, a taxing jurisdiction, or the state; is an employee of a county, a taxing jurisdiction, or the state; <br />or in the same tax year that he/she services the Board as a special magistrate, represents a. party before the Board in <br />any administrative review of property taxes. <br />Are you. an elected or appointed official or employee of a county, a taxing jurisdiction, or the state? ❑ Yes &6 No <br />If yes, please provide details: <br />Vie undersigned certifies, under penalty of disqualification from consideratio7l, that each iteral. contained in this <br />application, or ally other document furnished by or oil behalf of the applicant is true alld complete as of Che date it <br />bears. The tinde7sigiled authorizes the Value Adjusfinent.Board to obtain it fonnation front other sources to verify <br />each item conNined herein. The undersigned ack towledges that, if selected, heJshe will follow all requirem ell ts and <br />inandates of law in fu filling the dirties of special magistrate: <br />Date: <br />Stre of Applicant <br />Printed Name of Applicant <br />Page 3 <br />v01/13/2015 <br />-34- <br />