ETHICS COMPLAINT FORM

Provide the following information for the public officer or employee you allege violated the Nevada Ethics in Government Law, NRS Chapter 281A.

(If you allege that more than one public officer or employee has violated the law, use a separate form for each individual.)

Entity Type

City County State

Entity City

Entity County

Entity State

Public Entity

Public Office Title

Last Name

First Name

Street

City

State

Zip

Phone Work

Phone Other

Email

Describe in specific detail the public officer’s or employee’s conduct that you allege violated NRS Chapter 281A.

(Include specific facts and circumstances to support your allegation: times, places, and the name and position of each person involved.)

Is the alleged conduct currently pending before another administrative or judicial body? If yes, describe:

Witnesses: Identify persons who have knowledge of the facts and circumstances you have described, as well as the nature of the testimony the person will provide.

Witnesses

Title/Entity

First Name

Last Name

Street

City

State

Zip

Phone Home

Phone Other

Email

Fax

Testimony/Notes

ETHICS COMPLAINT FORM

YOU MUST SUBMIT EVIDENCE TO SUPPORT YOUR ALLEGATIONS. (NRS 281A.710 through 281A.715.)
Attach all documents or items you believe support your allegations, including witness statements, public orprivate records, audio or visual recordings, documents, exhibits, concrete objects, or other forms of proof.

Attach all Evidence Documents
- One file per document - Choose "Add Line" to add additional items -

	Document Name	Document Path

When uploading attachments, please note that only the following file formats are accepted:

Document: .txt, .rtf, .pdf, .doc, .docx, .ppt, .pptx, .pps, .ppsx, .odt, .xls, .xlsx
Images:.jpg, .jpeg, .png, .gif,.tif
Video:.mp4, .m4v, .mov, .wmv, .avi, .mpg
Audio:.mp3, .m4a, .ogg, .wav

Requesters Last Name

Requesters First Name

Street

City

State

Zip

Email Address

Phone Day

Phone Evening

Your identity as the Requester will be provided to the Subject if the Commission accepts jurisdiction of this matter, unless:

Pursuant to NRS 281A.750, I request that my identity as the requester of this Ethics Complaint remain confidential because (please check appropriate box):

Please check appropriate box:

I am a public officer or employee who works for the same public body, agency or employer as the subject of this Ethics Complaint. Provide evidence of your employment with the same public body, agency or employer.

OR

I can show a reasonable likelihood that disclosure of my identity will subject me or a member of my house-hold to a bona fide threat of physical force or violence. Describe in the text box below, or in an attachment, the facts and circumstances that support a reasonable likelihood of a bona fide threat of physical force or violence.

Provide evidence or describe threat:

A copy of this Complaint will be provided to the Subject. If your request for confidentiality is approved by the Commission, the Complaint will be redacted to protect your identity as the Requester. The Commission may decline to maintain the confidentiality of your identity as the Requester for lack of sufficient evidence of your employment status with the same public body, agency or employer, or proof of a bona fide threat of physical force or violence.

If the Commission declines to maintain my confidentiality, I wish to:

Withdrawl my Complaint,OR

Submit the Complaint understanding that the Subject will know my identity as the Requester.

Signature

By my signature below, I affirm that the facts set forth in this document and all of its attachments are true and correct to the best of my knowledge and belief. I am willing to provide sworn testimony regarding these allegations. I acknowledge that this Ethics Complaint, the materials submitted in support of the allegations, and the Commission’s investigation are confidential unless and until the Commission’s Review Panel renders a determination. Certain Commission procedings and materials, including the Investigatory File remain confidential pursuant to NRS 281A.750 through 281A.760.

Clear

Print Name

Submission Date

4/20/2024