| Ethics Commission, North Dakota

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Reporting Official's Name

Associated Entity/Organization Name

Name of Disclosing Official

Title/Position of Disclosing Official

Phone Number

Email Address

Detailed Description of Potential Appearance of Bias

Did the appearance of bias involve a party to the proceeding?

Yes

Did the appearance of bias involve the issues of the proceeding?

Yes

Did the appearance of bias involve campaign monetary or in-kind support*

Yes

*For a definition of “campaign monetary or in-kind support” please see N.D. Admin. Code § 115-05-01-02(2).

What is the size of the campaign monetary or in-kind support?

What is the degree of involvement in the campaign?

Did the campaign monetary of in-kind support include the current or immediately preceding election cycle?

Yes

Please provide information on the final determination, process for determination, and determining individual or body

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Certification

I certify that the information provided in this disclosure form is true, correct, complete, and of my own personal knowledge. I will fully cooperate in the process regarding this disclosure form.

Signature

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Quasi-Judicial Bias