Physician'S Statement For Terminally Ill Care Of Family Member - Alaska Permanent Fund Dividend Division - 2010
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104605
04605
Alaska Department of Revenue
Alaska Department of Revenue
PFD Division Use Only
Permanent Fund Dividend Division
Permanent Fund Dividend Division
Physician's Statement for Terminally Ill
Physician's Statement for Terminally Ill
ALN
Care of Family Member
Care of Family Member
To complete the processing of your Permanent Fund Dividend (PFD) application, the following form must be
To complete the processing of your Permanent Fund Dividend (PFD) application, the following form must be
completed by the applicant, patient or patient's parent or guardian, and the attending physician. Use this form
completed by the applicant, patient or patient's parent or guardian, and the attending physician. Use this form
when the applicant provided care for a family member who is/was terminally ill and is legally related to the
when the applicant provided care for a family member who is/was terminally ill and is legally related to the
applicant through marriage or guardianship; a sibling, parent, grandparent, son, daughter, grandson,
applicant through marriage or guardianship; a sibling, parent, grandparent, son, daughter, grandson,
granddaughter, uncle, aunt, niece, nephew, or first cousin.
granddaughter, uncle, aunt, niece, nephew, or first cousin.
Applicant, complete the following:
Printed Name
Daytime Telephone Number
Social Security Number
Date of Birth
Message Telephone Number
Mailing Address
Email Address
City
State
Zip Code
Absence Begin Date
Absence End Date
Month
Day
Year
Month
Day
Year
Write additional dates on the back of this form.
I am/was out of Alaska for the purpose of providing care for my family member (check one)
I am/was out of Alaska for the purpose of providing care for my family member (check one)
legally related through
legally related through
marriage or guardianship;
sibling,
parent,
grandparent,
son,
daughter,
grandson,
granddaughter,
uncle,
aunt,
niece,
nephew or
first cousin who is/was terminally ill.
Signature of Applicant
Date
Patient or Patient's parent or guardian, sign the medical release below:
I authorize my attending physician to provide the information requested below to the Alaska Permanent Fund
Dividend Division.
Patient's printed name
Patient's date of birth
Patient's or legal guardian's signature
Date
Attending physician, complete the following:
I am the physician for the patient named above who, in my opinion, is/was terminally ill.
Signature of Licensed Health Care Provider
Date
Printed Name of Licensed Health Care Provider
Mailing Address of Physician
Telephone Number
City, State, Zip Code
Briefly describe the patient's terminally ill condition.
Send this completed form to:
Alaska Department of Revenue
Permanent Fund Dividend Division
PO Box 110462
04605
Juneau, Alaska 99811-0462
04606 (Rev. 06/10)
04606 (Rev. 06/10)
Confidential
Confidential
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