CONFIDENTIAL
ETHICS SUPERVISOR DETERMINATION FORM
(Board or Commission Member)
Board or Commission:
Member Disclosing Potential Ethics Violation:
I have determined that the situation described on the attached ethics disclosure form
does or would violate AS 39.52.110 - .190. Identify applicable statute below.
does not or would not violate AS 39.52.110 - .190.
Signature of Designated Ethics Supervisor (Chair)
Printed Name of Designated Ethics Supervisor
Date:
COMMENTS (Please attach a separate sheet for additional space):
Note: Disclosure Form must be attached. Under AS 39.52.220, if the chair or a majority of the board or
commission, not including the disclosing member, determines that a violation of AS 39.52.110-39.52.190 will exist
if the member participates, the member shall refrain from voting, deliberating, or participating in the matter. A
member will not be liable under the Ethics Act for action in accordance with such a determination so long as the
member has fully disclosed all facts reasonably necessary to the determination and the attorney general has not
advised the member, chair, or board or commission that the action is a violation. Forward disclosures with
determinations to the State Ethics Attorney as part of your quarterly report. Quarterly reports are submitted to
Litigation Assistant, Opinions, Appeals & Ethics, Department of Law, 1031 W. 4
th
Avenue, Suite 200, Anchorage,
AK 99501.
Revised 2012