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o iyr6r£ <br />i SI UXIAL MAGISTRATE APPLICATION <br />IND[A:N RIVERCOUNTY VALUE ADJUSTMENT .BOARD <br />(APPLICANTS 011 I'LINf?D iN FLA—'STAT, ']O,I Q ) <br />Have you ever been disbarred, suspended or received any other disciplinary action, From any organized <br />association, or from the State.of Florida? X No ❑ Ycs (please explain) <br />4. List any personal or business relationship you have ever had with any officer or employee of theoffice of the <br />property appraiser, of iccof the clerk_ol'the circuit coum, office of the county attorney or the valise adjustment. <br />board of any cif the cciuntics to which you are applying:. <br />5.. List any clubs, organizations, associations, or other entitiesto which you belong.or participate. in and in which a <br />possible conflict of interest could occur or the appearance of con lietof interest might arise that would prevent <br />you fioi» fairly conducting the hearing between the property appraiser and the property, owner andJaxpayer. <br />Pursuant to F la. Stat. § 194,035, a person; cannot serve as a special :magistrate if he/she is an elected or appointed - <br />official :of a comity, a taxing.jurisdiction, or the state: is an employee cif a county, a Taxing jurisdiction, or'the state: <br />or in the sante tax year that he/she services the Board as a special magistrate, represents a party before the Boardiin <br />any administrative review ofprop ty bites. <br />Are you an elected or appointed official or employee of a county, a taxing jurisdiction, or the state'l.0 Yes No <br />if cs, please provide details: <br />The uiulersigneol cerlr/ies' under venally of rlisduolif.cation.,fi-am co nsidercttion, that each itent co nlainecl in this <br />al) plicatldn, or an1v other tlocuinenl fiirnished br' or on behalf Rf the cy)plicam is trite and complete as gfdhe- date =it <br />bears. the IU d6 ,-.ISi ne(l auth<' izes 7lie a`ahle f (I ustmenl Boarcl to obtain nlformution,i•oll o1hei- s'od reas to verify <br />each stem conialnu(l h(wein, The-unclersigneel acl(nowle(kws that. 7fseleue(f he,sho wi l./b/l'lJw all i-e+quirements:find <br />mandates of'haliv ip-MI-11 'ng the ' te. cafslaecial inatrislrole: <br />t C.` Cate: C 7� <br />Sigttatttre of ,1p alicani <br />Printed N tine of Applicant <br />Pne, 3 <br />N,01/13/2015 <br />-106- <br />