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SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVER COUNTY VALUE ADJUSTMENT BOARD <br />{APP`LICANTS M UST MEET QUALIFICATIONS OUTLINED IN FLA, STAT, 6 194;035 <br />2. Of those organizations describe any possible conflict of interest that could occur or the appearance of a conflict <br />of interest that may prevent you from fairly conducting a hearing: <br />none <br />3. Have you ever been disbarred, suspended or received any other disciplinary action from any organized <br />association, or from the State of Florida? XXn 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 count, office of the county attorney or the value adjustment <br />board of any of the counties to which you are applying: <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 might::ar se that would prevent <br />you from fairly conducting the"hearing between tate property appraiser and the property owner and taxpayer: <br />I don't belong to any club or organization that would prevent me, from fairly condup <br />ji—fmabooligg. 1 do'beloag <br />to the Garden Club of Indian River County and the Vero Beach Country Club <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;;or' <br />in the same tax year that he/she services the Board as a special magistrate, represents a party before the Hoard in any <br />administrative review of property taxes. <br />Are you an elected or appointed official or employee of a county, a taxing jurisdiction, or the state? El Yes XXM <br />No <br />If yes, please provide -details: - <br />The: undeesigned certifies, under penalty of disgiialxiftatfonftom consideration, that :each iters eonWined-in this <br />application, or any other document fivwished by or on behat(of the applicant is true,and complete as of the date it <br />heats. 71te undersigned authorizes the Value Adjustment Hoard: to obtain information from other sources to verify <br />each item contained herein. The undersigned acknowledges that, if velected, he/she will fllow all requirements and <br />mandates of law in f idling the duties of special magistrate. <br />ig' ature of Applicant <br />Date: �- �'vA)�. <br />A-1 <br />Printed Name of Applicant <br />Page 3 <br />v0111312015 <br />-56- <br />