2009 Adult Application Form - Alaska Department Of Revenue printable pdf download

Alaska Permanent Fund Dividend

04001

2009 Adult Application

(Adults 18 and older on date of application)

mALE

SOciAL SEcUritY NUmBEr

DAtE OF Birth

FEmALE

Month

Day

Year

Failure to provide a SSN will subject your dividend to 28% backup withholding by the IRS.

FirSt NAmE

m.i. LASt NAmE

mAiLiNg ADDrESS

APt #

citY

StAtE

ZiP cODE

PhYSicAL ADDrESS

APt #

citY

StAtE

ZiP cODE

(Write “Same” if same as mailing address)

DAYtimE tELEPhONE

mESSAgE tELEPhONE

E-mAiL ADDrESS (optional)

(

)

(

)

Shade circles like this:

Not like this:

List two adult Alaska residents who can verify your residency.

1. Did you receive a 2008 dividend? Answer YES even

YES

if your dividend was assigned or garnisheed. If NO,

Full Name

complete Question 11b on the back of this form AND the

entire Adult Supplemental (AS) Schedule. Attach the

Mailing Address

AS form to this completed application.

City, State, Zip Code

Daytime Phone #

2. Are you physically in Alaska today? Answer NO if you

YES

are completing this application or mailing this application

Full Name

from someplace other than within Alaska. If NO, complete

Question 8 on the back of this form and Parts B & C of

Mailing Address

the Adult Supplemental (AS) Schedule. Attach the AS

form to this completed application.

City, State, Zip Code

Daytime Phone #

3. A. During 2008, were you gone from Alaska more

YES

read the Following Statements and Sign Below

than 90 days total?

If YES, complete Question 8 on the back of this

i certify that:

form AND Parts B & C of the Adult Supplemental

• I am now and intend to remain an Alaska resident indefinitely.

Schedule and attach it to this completed application.

• I was an Alaska resident for all of 2008.

• I have not claimed residency in another state.

B. During 2008, were you gone from Alaska more

YES

• I was in the state of Alaska for at least 72 consecutive hours in

than 180 days total?

2007 or 2008.

If YES, complete Questions 8 through 10 on the back

i understand that if what i say is not true, it is a criminal offense and

of this form AND Parts B & C of the Adult Supplemental

if i am convicted, in addition to any criminal penalties:

Schedule and attach it to this completed application.

• I will lose this and all future dividends.

• I will be required to pay back all dividends I have been paid.

Failure to disclose absences may result in the denial of

your application.

i understand that if i deliberately misrepresent or recklessly

disregard a fact, i am liable for civil penalties:

4. Are you a United States citizen? If NO, complete Ques-

YES

• I could lose this dividend and my next five dividends.

tions 12 and 13 on the back of this form.

• I may have to pay a fine of up to $3,000.

5. At any time since December 31, 2007, were you on active

YES

duty as a member of the U.S. Armed Forces or activated

release of information: I authorize the Alaska Department of Revenue

as a member of the U.S. Guard or Reserve?

to obtain confidential information necessary to verify my eligibility. I

authorize the release of confidential records necessary to verify

Civilians, non-activated Alaska National Guard members

my eligibility from any public agency including the Social Security

and Alaska Reservists, answer NO.

Administration; Internal Revenue Service; Alaska Department of

Health and Social Services, Division of Public Assistance and Office of

6. Do you want to place 50% of your dividend in the UA Col-

YES

Children’s Services. I agree that a copy of this authorization is as valid as

lege Savings Plan? See page 29 for a description of the

the original.

plan.

i certify that the information i am supplying on and with this form is

7. A. Do you want your dividend deposited directly into your

YES

true and correct.

bank account? If YES, deposit into:

Your Signature

Date

Same account as last year

________________________________________________________

New account listed below

By submitting this application with or without signature i am

consenting to registration with the U.S. Selective Service System, if

NEW ACCOUNTS ONLY, fill in information below. See page 9 for instructions.

so required by law.

Bank

Account type

code

Checking

Savings

(Select one)

Voluntary Veteran’s information can be provided on the

New Account Number

back of this form.

04001

Your application must be received by the PFD Division or postmarked by March 31, 2009.

2009 Adult Application Form - Alaska Department Of Revenue

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