Fillable Value Adjustment Board Application (Lee County Government)

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Value Adjustment Board Application (Lee County Government)

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The Value Adjustment Board Application (Lee County Government) form is 4 pages long and contains:

  • 1 signature
  • 22 check-boxes
  • 25 other fields

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File type: PDF

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Value Adjustment Board Application
(Please Type or Print)
The citizen appointed by the Lee County Board of County Commissioners to the Lee County Value
Adjustment Board must meet all of the following statutory requirements:
1. Must own
homestead property within Lee County, Florida
2. May not be a member or employee of any taxing authority
3. May not be a person who represents property owners, property appraisers, tax collectors or taxing
authorities in any administrative or judicial review of property taxes.
Personal Information
Title: [ ] Mr. [ ] Mrs. [ ] Ms. [ ] Other:
Name:
Last First Middle Initial
Home Address:
Street City Zip Code
Parcel STRAP No.:
Business Address:
Street City Zip Code
Mailing Address:
Street City Zip Code
Phone:
Home Cell Business
Fax:
E-mail Address:
Occupation:
My qualifications to be eligible are as follows:
Lee County Administration | 2115 Second Street | Fort Myers, FL
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
Value Adjustment Board Application
(Continued)
Civic / Professional Accomplishments / Offices Held
If applicable, indicate any employment, contractual relationship or status that you may have, or have had within the
past 12 months, with any private business entity that rents, leases or sells any realty, or provides any goods or services
to the County or that is conducting any business with the County.
Are you a member or employee of any taxing authority or an advisory committee member to any taxing authority in
the State of Florida? If so, list the name(s) of the taxing authority or advisory committee:
Do you represent property owners, property appraisers, tax collectors or taxing authorities in any
administrative or judicial review of property taxes?
[ ] Yes [ ] No
Have you ever worked for the Lee County Board of County Commissioners? If ‘Yes’, list position,
department, start & end date.
[ ] Yes [ ] No
Do you have any relatives currently working for the Lee County Board of County Commissioners?
If ‘Yes’, list name(s) & department(s).
[ ] Yes [ ] No
If applicable, attach a resume of additional personal and professional qualifications and experience.
I hereby submit my name for consideration to serve as the Board of County Commissioners’ citizen appointment
to the Lee County Value Adjustment Board and do hereby acknowledge that I have read and understand the
statutory requirements listed for serving as the Board of County Commissioners’ citizen appointment to the Lee
County Value Adjustment Board. I am attesting that I meet all of these requirements. I acknowledge that if it is
determined that I do not meet these requirements, my application will not be considered. I understand that if I
am appointed by the Lee County Board of County Commissioners to serve as the citizen appointment to the Lee
County Value Adjustment Board, I serve at the pleasure of the Lee County Board of County Commissioners and
may be removed from this appointment for failure to comply with the statutory requirements or at the pleasure
of the Board of County Commissioners.
Signature
Date
Lee County Administration | 2115 Second Street | Fort Myers, FL
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
click to sign
signature
click to edit
Value Adjustment Board Application
(Continued)
Some Boards and Committees appointed by the Lee County Board of County Commissioners are required to
comply with Chapter 112, Florida Statutes, Financial Disclosure Law, and you may be required to file a Form 1
Statement of Financial Interests.
Lee County, an Equal Opportunity Employer, considers the selection and appointment of persons to advisory
committees in a non-discriminatory manner consistent with the requirements of Federal, State and Local non-
discrimination laws.
Return completed form:
Lee County Administration
Value Adjustment Board
P.O. Box 398
Fort Myers, FL 33902-0398
Lee County Administration | 2115 Second Street | Fort Myers, FL
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
Value Adjustment Board Application
(Continued)
Committee ID# ________________________
(Office Use Only)
Lee County complies with Federal, State and Local laws, regulations and guidelines that prohibit
discrimination based on race, sex, color, national origin, handicap, age or marital status.
STATUTORILY CREATED REQUIRED COMMITTEE REPORTING DATA
Lee County is required by the State of Florida to collect and maintain the information requested below for
statistical reporting purposes only. This information will be maintained separately from your application and
will not be considered in the application evaluation process.
The information provided is required by State Statute, however, you have the right not to disclose any or all of
this information. This form
must be returned to Lee County Administration.
Gender:
Male
Female
Choose Not to Disclose
Handicapped / Disabled:
Yes
No
Choose Note to Disclose
RACIAL / ETHNIC DATA (CHECK ONE)
WHITE (Not of Hispanic Origin): All persons having origins in any of the original people of Europe,
North Africa or the Middle East.
BLACK (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
ASIAN OR PACIFIC ISLANDER: All persons having origins in any of the original Peoples of the Far
East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example:
China, Japan, Korea, the Philippine Islands and Samoa
AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any of the original
Peoples of North America and who maintain cultural identification through tribal affiliation or
community recognition.
HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin regardless of race.
CHOOSE NOT TO DISCLOSE
Lee County Administration | 2115 Second Street | Fort Myers, FL
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
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Value Adjustment Board Application (Lee County Government)

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Completed 19 July 2020

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