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, SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVKR COILINTY VALUE ADJUSMENT BOARD <br />(APPUCAN'I'$Mt4'V,,tet EKtQv4uFK:,k"$OUrl�,MW IN I IA- SI A 1.1:1414.tus) <br />2. Of those oiVnizations describeagy possible conflict ofinterest tW could occur or the aMorom of a conflict <br />or interest that nivy prevent you from (hirly cmducting.4 hearing; <br />3. Have you ever been disbarred, suspendeder received any other disciplinary action fhwn anyorgani/ed <br />association, or *m die State of Floridn? W o (J Yes (please explain) <br />NO <br />4. Ust any, personal or business relationship you have ever had with any officer or emplayee of We office of the <br />property appraiser, oMce of the clerk of the circtilt towt oMce or the count), attorney <br />or the vahie adjustment <br />board of any of the counties to which you sere applyintg: <br />5. List any clubs, orgaoizittiont, associations. or other entilks to which you be or participate in and inwhich a <br />possiblevooffict of Interest could owur or thea of,% amflia of Wow WOW arise that would prevent <br />you, rNm birly vooductift the bearing, between the propally qpr*a NW the pimperty owner Out! taxpayer. <br />NONE <br />Purstiant to Fla. SOL 4 194,035. a person cannot serve as a speclat magistrite if he/she is .0 elected or appointed <br />ot1ficial ol'a county. a minSjurisdictio". or the state: it an employee or a county. a taxing jurwktw, or the state: <br />or in the sairic tax year that he/she services the Board as a sromial in istmic—reprcurds a party before the Board in <br />any administrative review of property crises. <br />Are you an elected or appointed ofricial or employee ora county. a taxing jurisdiction, or the state'' [3 Yes ewo <br />If yet, pitm provide details; big - <br />77w im*rsigned cerr#k* under pemM., a <br />.f d!xqWd#7cvW*fi"W cmvM"10ft, dW ear Item MM~ In rhis <br />w*w fwnbW 19, or on Is if of 116 &*&-um Is irm am/ cmpktr 4& o <br />(q)PIk"atm, or 0001fthe Jaw It <br />Mors. 7T7a xndar nad ate the &mrd io okdn other NWC4% to rerill, <br />'voch Roan t1wonwN d J it AW. fsdear4. heshe irlif NkArall Modreau-nix tole/ <br />WanAves 14f, in, e mogisswo. <br />FT <br />Signature <br />Printed <br />9Ft-JM <br />