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*� * SPECIAL MAGISTRATE. APPLICATION <br />INDIAN RIVE, R COUNTY VALUE ADJUSTMENT BOARD <br />IN <br />of interest that. may prevcn. t.you from fairly conducting a hearing: <br />NIA• <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? 1 No, El Yes (please explain) <br />A. 'List any personal or business relationship you'have ever had.•with any officer or emplpyce of the office of the <br />propertyjappraiser, office of the clerk ofihe circuit court, office of the county attorney or the value adjustment <br />board ofanyof the counties to which you are:applying: <br />N/A <br />5. List any clubs, organizations, associations, or:other entities to which you belong or participate in and in which a <br />possible i onflIct. of interast;couId occur Or the appearance of a:con nict of interest it! ighI,ar-ise that would prevent <br />you from fairly conducting the =hearing between the propertyappraiser-and the properfy owneratid`.taxpayer. <br />Pursuant to Fla. Stat. § 194:03.5, a•person:cannot serve as a speoial Magistrate if he/she is an elected or appointed <br />official ofa_county; a taxing jurisdiction, or the state; is an employee of a county, a taxing. jurisdiction, or the state; <br />or in the same -tax year that he/she services. the Board as a special magistrate, represents a party before the Board iii <br />any administrative review of.prdperty taxes. <br />Are you an elected or appointed official or employee of a county, a taxing.jurisdictiont or the state? ❑ Yes ❑ No <br />If yes, please provide details: <br />'/'he unders*adcertifies, colder penal(), of llisgtrrtlrficrrfivn fr•ow cons&lerrrtion, that each 'hent contained in /his <br />application, or. any other docittueni fiernishecl by &on heha f of the applicant is true ant! complete as of ffie date it <br />boars.. The under sa'ned,girl od es glue 4cl{ttstnrerrl.l3oartllo obtain- irfdrmal on frtom olb& sovrew to ver <br />each item con i�t�cl herelit earl igr d acA*pjple T elected hei:she will ftillati, attregtrir•ements and <br />mandates of Ift, in fir /lln t 'e �IitNes o sp Wale.. <br />Date: /20/2022 <br />Signature of <br />(Tinted <br />Page 3 <br />vp.tM/2013 <br />-15- <br />