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SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVER COUNTY VALUE ADJUSTMENT BOARD <br />(APPLICANTS MUST MEET QUAL[fiCATioNS OUTLINED IN I' iA S'Ll 1 $ 110151 <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 Q 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 />NONE <br />S. 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 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 />NONE <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 Board 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? [] Yes M No <br />Ifyes, please provide details: <br />lite undersigned certifies, under penalty of clisqualiTcmion from consideration, that each !tett contained in this <br />applicailon, or any other doctanent furnished 4- or on hehalf of the applicant is true and complete as of the date it <br />bears. The undersigned artthorizes the !slue Adjustment Board to obtain *ormation from other sources to ver?& <br />each iteJJ�C l/tt[U71N drain. Tito undersigned acknotrledges that. ifselected. he/she trill fr /Mis all requirements and <br />mandaft��lllbtg the ditties gfspeclal magistrate. <br />of <br />of <br />Date: IN2024 <br />2024 <br />Page 3 <br />rt)1! 131201 S <br />-2f- <br />