Form 08155 - Audit - Alaska Permanent Fund Dividend - 2009
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108155
Alaska Permanent Fund Dividend
2010 Audit Form
SOCIAL SECURITY NUMBER
DATE OF BIRTH
Month
Day
Year
FIRST NAME
M.I.
LAST NAME
I certify that the information I am supplying on and with this form is true as of the date of my original application. I understand that a false statement made
on or with this form will subject me to the same penalties disclosed on my original application.
(Your signature is required)
Date
Questions 1-3 intentionally excluded
4
A
. Were you absent from or living outside of Alaska when you fi led your application?
.
Yes
No If NO, go to Question 5A
B.
If YES, are you returning to Alaska to remain indefi nitely?
Yes
No
C
. If YES, when did you depart Alaska? AND when are you returning to remain indefi nitely?
Month
Day
Year
Month
Day
Year
5
A
.
. Are you married?
If NO, go to question 6
Yes
No
B
Yes
No
. If you are married, is your spouse applying for this year's dividend?
If NO, attach an explanation
6
A
. Have you maintained your principal home or stored the majority of your
.
Yes
No
household belongings in Alaska continuously since December 31, 2008?
B
Own
. Do you
Lease or Rent
Live with parents
Other (attach explanation)
Store
C
. Physical address of home or storage: _______________________________________________________________________________________________
______________________________________
_________________
_________________
CITY:
STATE:
ZIP CODE:
7.
At any time since DECEMBER 31, 2008 have you:
A.
A.
Maintained your principal home outside of Alaska?
Yes
No
Did you:
Own
Lease or Rent
Live with parents
Other (attach explanation)
Address
City, State, Zip Code
State
B.
B.
Claimed residency in another state or country in your employment records, including leave and
Yes
No
earnings statements if you are a member of the U.S. Armed Forces?
Vehicle Plate #
C.
C.
While living in Alaska, registered a vehicle as the owner or co-owner and claimed a non-resident Alaska
Yes
No
motor vehicle tax exemption?
State
D.
D.
Yes
No
Accepted full-time permanent employment in another state or country?
State
E.
Yes
No
E.
Filed or you will be required to fi le a 2009 resident or part-year resident income, personal property, or
excise tax return in another state or country? If YES, attach a copy of the return.
State
County
F.
F.
Yes
No
Claimed a homestead property tax exemption in another state or country? If YES, attach an explanation
and copy of the homestead exemption law.
Date
State
G.
G.
Yes
No
Applied for or received a student loan from another state or country? If YES, attach a copy of
the application.
If you received a federal Staff ord, Sallie Mae, Nellie Mae or Bank loan, answer NO.
State
Date
H.
H.
Yes
No
Disclosed in a court proceeding or affi davit that you are a resident of another state or country?
If YES, attach a copy of the affi davit or documents.
Date
State
I.
I.
Executed a will which described residency in another state or country? If YES, attach a copy
Yes
No
of the will.
Date
State
L.
L.
Yes
No
Moved from Alaska and claimed or will claim moving expenses as a deduction on your 2009 federal
Date
income tax return? If YES, attach a copy of the return.
State
M.
M.
Yes
No
Registered to vote in another state or country?
Date
State
N.
Yes
No
N.
Voted in a local or state election in another state or country?
State
Date
O.
Yes
No
O.
Purchased a resident hunting, fi shing or trapping license in another state or country? If YES,
attach a copy of that state’s or country’s license regulations.
Date
State
P.
P.
Filed for divorce, dissolution or legal separation in another state or country? If YES, attach
Yes
No
a copy of documents.
Date
State
Q.
Q.
Obtained benefi ts as a result of establishing or maintaining a claim of residency in another state or
Yes
No
country? If YES, attach an explanation.
Vehicle Plate #
State
R.
R.
Maintained a vehicle registered in another state or country or obtained or renewed another
Yes
No
state's or country's vehicle registration?
State
License #
S.
Maintained a driver’s license in another state or country or obtained or renewed another state’s or
Yes
No
S.
country’s driver’s license?
Confi dential
08155
PO Box 110462, Juneau, AK 99811-0462
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