"Ethics Disclosure: Interest in State Grant, Contract, Lease, or Loan" - Alaska

Ethics Disclosure: Interest in State Grant, Contract, Lease, or Loan is a legal document that was released by the Alaska Department of Law - a government authority operating within Alaska.

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  • Released on January 1, 2012;
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Ethics Disclosure Form
Interest in State Grant, Contract, Lease, or Loan
TO:
, Designated Ethics Supervisor
(Agency, Public Corporation, Board, Commission, Council)
As required by AS 39.52.150(d), this disclosure reports a personal or financial interest held by
me or a family member and awarded, executed, or administered by the agency that I serve:
contract
state grant
lease
loan
The state grant, contract, lease, loan was awarded on
by:
Describe the grant, contract, lease, or loan:
Identify the Recipient(s) of the grant, contract, lease, or loan:
My financial or personal interest in the grant, contract, lease, or loan is:
Official action I can take regarding the grant, contract, lease or loan is:
I certify to the best of my knowledge that my statement is true, correct, and complete. In
addition to any other penalty or punishment that may apply, the submission of a false statement
is punishable under AS 11.56.200 - AS 11.56.240.
(Signature)
(Date)
(Printed Name)
(Division)
(Position Title)
(Location)
(Work Supervisor's Signature)
(Date)
Approved
Action Required
Ethics Supervisor Determination:
(Date)
Designated Ethics Supervisor*
*Designated Ethics Supervisor: Provide a copy of the signed disclosure to the employee. If action is
required under AS 39.52.210 or AS 39.52.220, attach a determination stating the reasons and send a
copy of the determination and disclosure to the attorney general with your quarterly report.
Revised 2012
Ethics Disclosure Form
Interest in State Grant, Contract, Lease, or Loan
TO:
, Designated Ethics Supervisor
(Agency, Public Corporation, Board, Commission, Council)
As required by AS 39.52.150(d), this disclosure reports a personal or financial interest held by
me or a family member and awarded, executed, or administered by the agency that I serve:
contract
state grant
lease
loan
The state grant, contract, lease, loan was awarded on
by:
Describe the grant, contract, lease, or loan:
Identify the Recipient(s) of the grant, contract, lease, or loan:
My financial or personal interest in the grant, contract, lease, or loan is:
Official action I can take regarding the grant, contract, lease or loan is:
I certify to the best of my knowledge that my statement is true, correct, and complete. In
addition to any other penalty or punishment that may apply, the submission of a false statement
is punishable under AS 11.56.200 - AS 11.56.240.
(Signature)
(Date)
(Printed Name)
(Division)
(Position Title)
(Location)
(Work Supervisor's Signature)
(Date)
Approved
Action Required
Ethics Supervisor Determination:
(Date)
Designated Ethics Supervisor*
*Designated Ethics Supervisor: Provide a copy of the signed disclosure to the employee. If action is
required under AS 39.52.210 or AS 39.52.220, attach a determination stating the reasons and send a
copy of the determination and disclosure to the attorney general with your quarterly report.
Revised 2012