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SPECIAL MAGISTRATE APPLICATION <br />INDIAN RIVER COUNTY VALUE ADJUSTMENT BOARD <br />(APPLICAM MUST M= QUAPWAMNS OUMMD IN aA.: 5W, t 194& 1 <br />MEN"= 45) <br />2. Of thoso-organizations describe any possiblo conflict of interest drat could occur or the,appearaoce of a cotmict <br />of interest that. may prevent you from -fairly conducting a hearing., <br />N/A <br />Have you ever been disbarr4 suspandod or received any otherdisciplinary action from any organized <br />association, or from the State of Florida? 0 No 0 Yes (ply explain) <br />4. List any personal or business relationship you hive 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 attoxnqy 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 datitles to which you belong or participate in and in which a. <br />possible conflict of interest could occur or the appeamp ofa,QqfiftofJW ' <br />jm'. in ightarlse.thatwould prevent <br />you frons fairly conducting the hearing between the "arty appraiser and the property owner and taxpayer. <br />None <br />Pursuant to Fla. Stat, § 194.03$, a person cannot *serve: as a, special inagistraft if he/she is an elected or aMointed <br />official of a county, a taxing jurisdiction, or the state; is an employee, of a county, a taxing Jur! diction. or the state; or <br />in the same tax year that he./she services the Board as a special magistrate, represents 6 porty be fore the Board <br />oardin. any <br />aftinistrative review of property taxes. <br />Are you an elected or appointed official or employee of a county, ataxing jurisdiction, orthe.state? [] Yes 0 No <br />if Yes, please provide details; <br />The, undersigned certifies, under penalty of disquali4bation froth o0*Aikraav;% AW each item contained in <br />Or apW other document furn ished by . or on behay of the applicant is true and co M#018. q* q(Me date it <br />Narl The WWWsigned authorizes the Nue A41ywnent Board to QUM$ 110mation <br />each item contained n. fivM; other sowees to' ver <br />hereioyr <br />Me Wdersigned acknowledges that fselected, hekhe will repirements and <br />mandates of aw infiYUling the duties of special meWirtmia <br />'77ate- 5/31/24 <br />Slgaature _Ot�AVVflcant <br />Tenie Peltier <br />Printed Name of Applicant <br />PAP3 <br />- 53 - x914=015 <br />