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. SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVER COUNTY VALUE ADJUSTMENT BOARD <br />(APPLICANTS MUST MEET QUALIFICATIONS OUTLINED IN PLA. STAT. G 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 df Florida? [l 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. adjustment - <br />board of any of the counties to which you are applying: <br />None. <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 aright arise that would prevent <br />you from fairly conducting the hearing between the property appraiser and the property owner and taxpayer. <br />None. <br />CERTIFICATION <br />Pursuant to Fla. Stat. § 194.035, 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 No <br />If yes, please provide details: <br />The undersigned certifies, under penalty' of disqualification from consideration, that each item contained in this <br />application, or any other document furnished by or on behalf of the applicant is true and complete as of the date it <br />bears. The under ed au • ' es the Value Adjustment Board to obtain information from other sources to verify <br />each item contained erein. The u ersigned acknowledges that, if selected, he/she will follow all requirements and <br />mandates of law in ful 'ng the duti of special magistrate. <br />Signa of Ap' <br />I <br />Printed Name of App icant <br />Date: S/l, 0-ola <br />Page 3 <br />v01/13/2015 <br />- 12 - <br />