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SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVER COUNTY VALUE ADJUSTMENT BOARD <br />(APPLICANTS MUST MEET QUALIFICATIONS OUTLINED IN FLA. STAT. §194,035) <br />of interest that may prevent you from fairly conducting a hearing: <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? ® 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 court, 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 arise that would prevent <br />You from fairly conducting the hearing between the property appraiser and the property owner and taxpayer. <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; <br />or in the same tax year that he/she services the Board as a special magistrate, represents a party before the Board in <br />any administrative review of property taxes. <br />Are you an elected or appointed official or employee of a county, a taxing jurisdiction, or the state? ❑ Yes ® No <br />If yes, please provide details: <br />The unclersipred certiftea', under penalty, of disqualification front consideration, that each item contained in this <br />application, or any other document furnished by or on behalf of the applicant is true and complete as of the date it <br />bears. The undersigned authorizes the Value Adjustment Board to obtain information from other sources to verb <br />each item contained herein. The undersigned acknowledges that, if selected, he/she will fbIlow all requirements and <br />mandates of law in fulfilling the duties r f special magistrate. <br />���Da�te&21/22 <br />Signature of Applicant <br />Terrie Peltier <br />Printed Name of Applicant <br />Page 3 <br />v01/13/2015 <br />-50- <br />