Form 04415 - Adult Information Change/addition Form printable pdf download

Form 04415 - Adult Information Change/addition Form

Alaska Department of Revenue

04415

PFD Division Use Only

Permanent Fund Dividend Division

PFD ALN: 20100

Adult Information

Change/Addition Form

Use this form to report a change in your name or add or correct your SSN with the Permanent Fund Dividend (PFD)

Division. The PFD Division will apply the change or addition to current year records and any other prior year records

that are still active. Attach a letter if you want this change applied differently. If you have a myAlaska account, log on to

myAlaska to update name changes in your profile in addition to completing this form.

First Name as last reported to PFD

Last Name as last reported to PFD

Social Security Number

Date of Birth

Daytime Telephone Number

Message Telephone Number

Change my First Name to

Change my Middle Initial to

Change my Last Name to

Add my SSN as follows

Correct my SSN to

I certify that I am authorized to make the changes listed above. If I did not file for the adult above, I must attach a Power of

Attorney. All adults must sign for themselves.

Signature

Date

SIGNATURE IS

REQUIRED

Printed name of the person who signed

Social Security Number

Email Address

Send this completed form to:

Permanent Fund Dividend Division

PO Box 110462

Juneau, AK 99811-0462

Phone (907) 465-2326

Fax (907) 465-3470

04415

Confidential

04415 (Rev. 10/09)

Form 04415 - Adult Information Change/addition Form