• Receipt of Gift or Interest in State Grant, Contract, Lease, or Loan

    Receipt of Gift or Interest in State Grant, Contract, Lease, or Loan

    Ethics Disclosure
  • I am reporting:*

  • If this is regarding interest in a contract, grant, lease, or loan that has not been issued yet, use the Request for Ethics Determination or Report of Potential Violation form.

  • This disclosure reports a receipt of gift to me or my immediate family member:*
  • 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:*

  • Interest in State Grant, Contract, Lease, or Loan

  • The state grant, contract, lease, loan was awarded on*
     - -
  • Can you take or withhold official action regarding the grant, contract, lease or loan?*

  • Receipt of Gift

  • See Ethics Information for Public Employees (AS 39.52) for more information on Improper Gifts (AS 39.52.130).

  • Is the gift valued in excess of $150?*
  • Is the gift connected to your position as a state officer, employee or member of a state board or commission?*
  • Can you take or withhold official action that may affect the person or entity that gave you the gift?*
  • Are there circumstances in which it could reasonably be inferred that the gift is intended to influence the performance of official duties, actions, or judgment?*

  • Good news! If you did not answer "Yes" to any of the above questions, you do not need to submit this form.

  • Date of receipt or award*
     - -
  • The gift was received by a member of my family.*

  • Certification

  • Find your Designated Ethics Supervisor listed on the Executive Branch Ethics webpage.

  • Should be Empty: