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SPWIAL,MAGISTRATB APPLICATION <br />INBIAN RIVER. CCRIM116.; VALUE AbRATIVIENT BOARD <br />OPPLIPANI:sM113CMEET QVALIFICATIONS:PUTI.;IMPINELAMAT. 04,M <br />Have .you ever ben ellsbarrp4,.sgsgetidM or ppeiyo .any: alter #0ti,on, <br />'assoili <br />ciation, or.frome`StateufFloritai DYfe.ts (Please 04004 " <br />• • - <br />4.. List ayii6Fstkal:peWizioltiatjtohji3bUIiTQeVeti bat wjth any ot6coro.±-,erriplOyee,tifthe office ottlie. <br />propetty"appi4i$04 office .olthe• clerk. of Vie.tifouitcourt, .office- of the county. aftotney,cir 'the =value adjustment <br />biard:eany Otte counties to which you are applyibg: <br />Dir4e, <br />pe.:0.`)OLA. in 1. • <br />. . . <br />5. LiStany.clubs, organiTations,7associations, :or Other yon.belcing.orpartieipafejtx-.apc1 <br />possible conflict of.'interest could. occur or tlie, appearance of a conflict ofiiiteresfmight arise that would preve4 <br />youfrom fairly tonaucting,the tealihg betweeniheproppriy:uppiper.a4d1he property OWnerandtaicpayer: <br />. . . . <br />Pur-Alant.:,to Fia: $44, § 19,40.35„ aP_dr.sorirparihot Sertre as a special inatisikate Wile/She is.:a.m.ielectetorappointed <br />official. of a:coanty, a-taxiug jurisdiction, dr the state, is An empIoye ofs county,.a.taxing.juristiegonibr'llie. state; <br />or in the kanie tax.:y.ear:that.heishe:serviceS thel3oard as a special•magiittaterepresents a party beioratie <br />anTad0.411WANe review 9-flgoPertYtaN9s. <br />Are y.on-arkeleCtet.or.appoiritedbfaCiator employ•ee, of a.countyia taxiligiurisdrction, or the:state?„0: Yes No <br />Ifyes, pleaseprovide'deiails: <br />, . <br />Thettiuder.sikheil 'Certiijiest. under lifigd.61.pfdi (111#c"allOn.;#otn eptistdereillim th.rii:Oeh it.ent ,edutORdih <br />thi <br />appl:Qath»t or any Ate?1ocwnnfrrnished by or On:behalf ottiicluppliCipg is 6110 and complete as of the.. date it <br />bears The ipidersfgriectinithorigs the Value .144histinehtiBO-4.:to. obiWitinkrinatiort.from oilier sources to veru <br />each item cprolitodWoroirrThe uhdersigited izelftfolfiegges that, Yselegled,..helShe-Olifolittiv all rcquirerncuts and <br />' <br />thandates-of. kr:futfiliih&theidutigs spea.citmO,VStMte. <br />$igiatiure o <br />• <br />Date <br />• <br />• <br />PAA,L-t) <br />i±feOiApplieari.t <br />Page 3 <br />v01/13/2615 <br />- 73 - <br />