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vIVER <br />:; • SPECIAL MACIST 4.'a.APLICATIO T.::. . <br />INTI -IAN :Ri VLl COUNT'V.•V.ALU : ANIOrmo �TT•E.OA . <br />APP.LICt NTS MUST M), t:QUALIFICATIONS'OUTGINI?1):IN PLA,STAT. & 194.03) <br />:. Have you ever .begin,;dist arred, .suspended .or receibed..•:auy..oiher...disciplinary action •from. any organized.: <br />•``association; orfrom,theState oflrlbrida?. o'..0 es:(please eit�ilai �) '• s • • <br />4. List any:personai,or nisiness:relationship•you-;have ever had :w4. of64:e :ar emplcyee:;of.tile:office ofttie' . <br />' property"appraiser, office of the clerk•of thecircuit.:court, office of the county:attorney.or the value' adjustment <br />board of any of the co iiities to' which you.are. applying: � • : .. • • • . <br />List 'any clubs, org?ii i�atioxls, assn ciatit ns, or, other entities to: which. you belong Or participate: in' and in which a <br />possible conflict of interest could ocCiir or the appearance of a conflict•'of int¢erestnught:arlsethat would prevent. <br />you from fairly.cimcli eting the.hearuig between e /).i.Ope appraiser andtlieproperty wirer and. taxpayer. <br />CERTIFICATION <br />Pursuant to Pla.: Stat; § 1 4:035;. a p rsop cannot Serve as a,. special': magistrate. if 110$11.e. is ani.d cit.electer• appointed. <br />cou <br />.. 'g <br />:. :.official :of a nty, a ta7cin.J unsdictorl, or. the:state; i5 an••employee :o#`a county; a taxing jurisdiction;;o3 the •state; . . <br />•or:inthesame.. tax year that he/she Services theBoard.as a speoial magistrate, represent a: party before:the.Boardin . • <br />. •anyaclimrnstrativ:e seview,ofparol <br />Are you an elected. or appoi ited.ofii, cial.or employee:of a county; a taxing,jurisdiction, or the•.state?:0 Yes <br />- If yes; please provide detail:: • <br />The undersigned;disqu'al cation from: con's deratiot•••that'each` item 'conta ned`-iii` this. ` <br />application, or airy other clocurnent furnished by of ori :behalf oftl e applicant zs, true'and complete• as•:of.the date it • <br />bears.:The'underszgn¢d: authorizes the Va124e:Adjustment Board to obtain:i zforinatzonz from other sources-to`verify .••: <br />each itemcontainQd•herei : 'he.undersigned•acknoivledgeS.th'itt zfselected:he/3fhewillfolloui• all and <br />mandates of lawin fulfilling tlierduties of special ?tiagistrate:••• .. <br />• Page 3 <br />v01/13/2015•. <br />=79=: <br />