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SPECIAL MAGISTRATE APPLICATION `•s INDIAN RIVER + COUNTY VALUE ADJUSTMENT BOARD (APPLICANTS MUST MEET QUALIFICATIONS OUTLINED fN Fl..r> STAT. '94.035) 2. Of those organizations describe any possible conflict of interest that could occur or the appearance of a conflict of interest that may prevent you from fairly conducting a hearing: 3. Have you ever been disbarred, suspended or received any other disciplinary action from any organized association, or from the State of Florida? XX[:] No ❑ Yes (please explain) 4. List any personal or business relationship you have ever had with any officer or employee of the office of the property appraiser, office of the clerk of the circuit court, office of the county attorney or the value adjustment board of any of the counties to which you are applying: Applied for homestead exemption in the property 'appraiser's office in 2015. I currently serve as chair to the CAC for the Indian River Count MPO> 5. List any clubs, organizations. associations, or other entities to which you belong or participate in and in which a possible conflict of interest could occur or the appearance of a conflict of interest might arise that would prevent you from fairly conducting the hearing between.the property appraiser and the property owner and taxpayer. ! don't belong to any club or organization that would prevent me from fairly conducting a hearing. I do belong to the Garden Club of Indian River County and the Vero Beach Corm" Club Pursuant to Fla. Stat. 4 194.035, a person cannot serve as a special magistrate if lie/she is an elected or appointed official of a county, a taxing jurisdiction, or the state; is an employee of a county; a taxing jurisdiction, or the state: or in the same tax year that he/she services the Board as a special magistrate, represents a party before the Board in any administrative review of property taxes. Are you an elected or appointed official or employee of a county, a taxing jurisdiction, or the state? El Yes Xx❑ No If yes, please provide details: The iatrlersigned certifies, tinder penally of disqualification fi•onr consideration, that each item contained in this application, or any other docennent furnished br behalf or on behaof the applicant is true and corrrplete as of the date it betas. The undersigned authorizes the Value Acjustnient Board to obtain information fr•otn other sources to verily each item contained herein. The undersigned acknowledges that, if selected; he/she will follow all requir-entents and mandates of late in fulf (ling the dutles of special magistrate. t; i. J't Date: Signature of Applicant j Printed Name of Applicant Page 3 v01tI3i2015 -24-