Free 50-708 Information Change for Arbitrator Registry - Texas

50-708 (1-07/2)

INFORMATION CHANGE FOR ARBITRATOR REGISTRY

CLEAR ALL FIELDS

SUSAN COMBS · COMPTROLLER OF PUBLIC ACCOUNTS
INFORMATION ON THIS FORM AND ALL ATTACHMENTS ARE SUBJECT TO DISCLOSURE UNDER THE TEXAS PUBLIC INFORMATION ACT. ALL OR PART OF THIS INFORMATION WILL BE PUBLISHED IN THE REGISTRY OF ARBITRATORS OR POSTED ON A WEB SITE AVAILABLE TO THE PUBLIC

Each person who is listed as an arbitrator in the Comptroller's registry must report to the comptroller in writing any material change in the information provided in the application within 30 calendar days of the change. Failure of the arbitrator to report a material change may result in the removal of the arbitrator from the current registry. FOR ASSISTANCE - If you have any questions about this application, contact the Texas State Comptroller's Office toll free at 1-800252-9121. The local number in Austin is 512/305-9999. The E-mail address is: [email protected] AMERICANS WITH DISABILITIES ACT- In compliance with the Americans with Disabilities Act, this document may be requested in alternative formats by calling toll-free 1-800-252-9121. FEDERAL PRIVACY ACT - Disclosure of your social security number is required and authorized under law, for the purpose of tax administration and identification of any individual affected by applicable law. 42 U.S.C. §405(c)(2)(C)(i); Tex. Govt. Code §§403.011 and 403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Tex. Govt. Code, and applicable federal law. PUBLIC INFORMATION ACT - Section 552.147, Tex. Govt. Code excepts social security numbers from disclosure. If this form is requested as public information, your social security number will not be released.
You have certain rights under Ch. 559, Tex. Govt. Code, to review, request, and correct information we have on file about you. Contact us at the address or toll-free number listed on this form. ON · TYPE OR PRINT IN BLACK INK · Do NOT write in shaded areas.

ARBITRATOR INFO.

1. Taxpayer number for reporting any Texas tax OR Texas identification number if you now have or have ever had one ........................................................................ 2. Social Security Number* (REQUIRED) ........................................................................................................................
* Your Social Security number is not subject to public disclosure according to Section 552.147, Tex. Govt. Code.

3. Individual's First Name, Middle Initial, Last Name, Suffix, (i.e., Jr., III, etc.)
First Name M.I. Last Name Suffix

4. Mailing Address, City, State, Zip Code with extension
Street number, P.O. Box, or rural route and box number

City

State/province

ZIP code

County (or country, if outside the U.S.)

CONTACT INFORMATION

Phone Number

5. Daytime phone number ................................................................................................................................... 6. E-mail address (optional)* ..............
*Your E-mail address is confidential according to Section 552.137, Tex. Govt. Code; however, by including the E-mail address on this form, you are affirmatively consenting to its release under the Public Information Act. Fax Number

7. Fax number (optional) ..................................................................................................................................... 8. Physical location
Street number, or rural route and box number (do NOT use PO Box)

City

State/province

ZIP code

County (or country, if outside the U.S.)

50-708-2 (1-07/2)

Page 2

9. Company name or affiliation

PROFESSIONAL INFORMATION

10. Applicant's current areas of appraisal or real estate expertise (within last ten years) include: Residential ............................................................................................................................................................ Commercial .......................................................................................................................................................... Minerals ................................................................................................................................................................ Agricultural .......................................................................................................................................................... Land ..................................................................................................................................................................... Other (please describe) 11. Applicant is willing to arbitrate (check all that apply): In person, at any location within the region/s or county/ies indicated. By teleconference. As a desk review of documentation submitted by the property owner and appraisal district. 12. Applicant certifies that he/she has a current license and/or certification and has attached a copy. If applicant has both a license and a certification, indicate which license or certification is primary. Renewals for the Arbitration Registry will be based on the expiration date of the chosen primary license or certification. A. Licensed as a real estate broker or salesperson under Chapter 1101, Occupations Code ...............................
License number Month Day Year

Years of experience Years of experience Years of experience Years of experience Years of experience Years of experience

PRIMARY
Expiration date Month Day Year

B.

Certified as a real estate appraiser under Chapter 1103, Occupations Code .........

TXCertification number Expiration date

PRIMARY

13. From the table on the following pages select the region/s and/or county/ies in which you are willing to conduct arbitration.

Information changes/updates submitted with this application are public information under the Public Information Act and will be posted on a Web site. Applications may be mailed to:
Texas Comptroller ­ Arbitrator Application - CHANGE Property Tax Division Post Office Box 13528 Austin, Texas 78711-3528

IF APPLICANT MAKES A FALSE STATEMENT ON THIS FORM, IN ANY ATTACHMENTS TO THIS FORM OR IN ANY INFORMATION SUBMITTED TO THE COMPTROLLER UNDER APPLICABLE LAW AND RULES, APPLICANT COULD BE FOUND GUILTY OF A CLASS A MISDEMEANOR OR A STATE FELONY UNDER SECTION 37.10, TEXAS PENAL CODE. THE COMPTROLLER MAY REMOVE A PERSON FROM THE REGISTRY OF ARBITRATORS AT ANY TIME DUE TO FAILURE TO MEET STATUTORY QUALIFICATIONS OR TO COMPLY WITH REQUIREMENTS OF LAW OR ADMINISTRATIVE RULE OR FOR GOOD CAUSE AS DETERMINED BY THE COMPTROLLER.
Month Day Date Year

50-708-3 (1-07/2)

Page 3 16. Social Security Number* (Same as #2 on Page 1) ......................................................................................................
* Your Social Security number is not subject to public disclosure according to Section 552.147, Tex. Govt. Code.

PLEASE INDICATE BELOW REGIONS AND/OR COUNTIES WHERE YOU WOULD BE WILLING TO CONDUCT ARBITRATIONS (Please check boxes)
To be an arbitrator statewide, check the "statewide" box only. Checking additional boxes will invalidate (cancel) the original selection.

STATEWIDE To be an arbitrator for a designated region that covers "all" listed counties, check the "region" box only. Checking additional county boxes within the same designated region or statewide box will invalidate (cancel) the original selection. To be an arbitrator for designated county/counties that does NOT include the entire region, check the designated county box(es) only. An arbitrator may select multiple county boxes throughout various regions. An arbitrator may have the option to oversee an entire region AND individual counties from other regions. For example, an arbitrator may oversee the Capital Region and individual counties from the Central Texas Region. ALAMO REGION
Atascosa Bandera Bexar Comal Frio Gillespie Guadalupe Karnes Kendall Kerr Medina Wilson

CAPITAL REGION
Bastrop Blanco Burnet Caldwell Fayette Hays Lee Llano Travis Williamson

CENTRAL TEXAS REGION
Bell Bosque Brazos Burleson Coryell Falls Freestone Grimes Hamilton Hill Lampasas Leon Limestone Madison McLennan Milam Mills Robertson San Saba Washington

COASTAL BEND REGION
Aransas Bee Brooks Calhoun DeWitt Duval Goliad Gonzales Jackson Jim Wells Kenedy Kleberg Lavaca Live Oak McMullen Nueces Refugio San Patricio Victoria

GULF COAST REGION
Austin Brazoria Chambers Colorado Fort Bend Galveston Harris Liberty Matagorda Montgomery Walker Waller Wharton

HIGH PLAINS REGION
Armstrong Bailey Briscoe Carson Castro Childress Cochran Collingsworth Crosby Dallam Deaf Smith Dickens Donley Floyd Garza Gray Hale Hall Hansford Hartley Hemphill Hockley Hutchinson King Lamb Lipscomb Lubbock Lynn Moore Motley Ochiltree Oldham Parmer Potter Randall Roberts Sherman Swisher Terry Wheeler Yoakum

50-708-4 (1-07/2)

Page 4

PLEASE INDICATE BELOW REGIONS AND/OR COUNTIES WHERE YOU WOULD BE WILLING TO CONDUCT ARBITRATIONS (Please check boxes)
To be an arbitrator for a designated region that covers "all" listed counties, check the "region" box only. Checking additional county boxes within the same designated region or statewide box will invalidate (cancel) the original selection. To be an arbitrator for designated county/counties that does NOT include the entire region, check the designated county box(es) only. An arbitrator may select multiple county boxes throughout various regions. An arbitrator may have the option to oversee an entire region AND individual counties from other regions. For example, an arbitrator may oversee the Capital Region and individual counties from the Central Texas Region. METROPLEX REGION
Collin Cooke Dallas Denton Ellis Erath Fannin Grayson Hood Hunt Johnson Kaufman Navarro Palo Pinto Parker Rockwall Somervell Tarrant Wise

NORTHWEST TEXAS REGION
Archer Baylor Brown Callahan Clay Coleman Comanche Cottle Eastland Fisher Foard Hardeman Haskell Jack Jones Kent Knox Mitchell Montague Nolan Runnels Scurry Shackelford Stephens Stonewall Taylor Throckmorton Wichita Wilbarger Young

SOUTH TEXAS BORDER REGION
Cameron Dimmit Edwards Hidalgo Jim Hogg Kinney La Salle Maverick Real Starr Uvalde Val Verde Webb Willacy Zapata Zavala

SOUTHEAST TEXAS REGION
Angelina Hardin Houston Jasper Jefferson Nacogdoches Newton Orange Polk Sabine San Augustine San Jacinto Shelby Trinity Tyler

UPPER EAST TEXAS REGION
Anderson Bowie Camp Cass Cherokee Delta Franklin Gregg Harrison Henderson Hopkins Lamar Marion Morris Panola Rains Red River Rusk Smith Titus Upshur Van Zandt Wood

UPPER RIO GRANDE REGION
Brewster Culberson El Paso Hudspeth Jeff Davis Presidio

WEST TEXAS REGION
Andrews Borden Coke Concho Crane Crockett Dawson Ector Gaines Glasscock Howard Irion Kimble Loving Martin Mason McCulloch Menard Midland Pecos Reagan Reeves Schleicher Sterling Sutton Terrell Tom Green Upton Ward Winkler