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h <br />Gi S.P,ECIAL MA;GISTRATE..APPLICATION <br />INDIAN RIVER COUNTY'VALUE ADJUSTMENT BOARD <br />(APPLICANTSMUST.MEET-QUALIFICATIONS OUTLINED 1N;FLA. STAT. S 194:03'5) <br />3. Have you .ever been disbarred, suspended• or received :any other disciplinary action from any organized <br />assoc'iation,.or from'the.State of Florida? ® 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 />property appraiser, office of the clerk of.the circuit court, office of the county attorney or the value adjustmenf <br />;board of atiy of the counties to -which you are applying - <br />Applied for homesteed :exemption irr the property appralsers:gffice In 2015. [.currently serve as chair.to_the CAC. for -the Indian River County <br />-5. Ust any clubs; organizations; associations; or other entities. to -Which you belong or participate.in and is -which a <br />possible -conflict of interest could occur or the appearance.of a-confli.et 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 />I ddnY'belong to any'cl& or organization that would preventme frdm fairly conducting.a hearing. I do [Selong to the. Garden Club of <br />the Vero Beach <br />CERTIFICATION., <br />Purswot:to Fla. -Stat.:§ 194:035; a person cannot serve as a special magistrate if.he/she.is.an elected or -appointed <br />offcial.ofa.dounty, a•tax dgjunsdiction,.or•the-state; ts.:an:employee:ofa;county;:•a:taxing.jurtsdtctton; orthe.state; <br />or in the same•'tax-year .thatle/she services the Board as a%special .magistrate, represents -a party before the Board in <br />any administrative review•bf property taxes. <br />Ara you A..elected or appointed official of employee of a.county, Ttazi.ng jurisdiction,..or the state? ❑ Yes WI No <br />If yes,,please provide details; <br />The:. a ideisikted:cer eh#, z1iddr penalty of disgttalifcation f -oh. consideration, that edph item contained in: this <br />applicatioir,: or any other document f trnished by or on baba f of. the applicant. is true and complete as of the date it <br />beats. Th'a unde/sigiied.aitthorizes the Y.alue Adjustment Bodrd to obtain inforination f vnt other sourees.to verify <br />each itent contained herein. The undersigned acknowledges that,, ifselected, he/she will follow all m Wkements and <br />mandates of latiw in f t filling the ditties of special magistrate. <br />-- �. Date: :J L) <br />ture'of`Applica t <br />Printed Name. of Applicant <br />Page 3 <br />v01/13/20•15 <br />-26- <br />