Form 14815 - Address Change Form
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204414
Alaska Department of Revenue
PFD Division Use Only
PFD ALN:
Permanent Fund Dividend Division
Address Change Form
Use this form to change your address with the Permanent Fund Dividend (PFD) Division. The PFD Division will
apply this address change to current year records and any other prior year records that have not been paid or
closed. Attach a letter if you want this address change applied differently. You must be an adult (18 or older) or
emancipated to change an address. All sections required. Requests with incomplete or incorrect
information will not be processed.
*The information that is currently on the record is required. If you do not know the current address information, provide
picture identification at one of PFD's offices or have this Address Change notarized. See back of form.
*Mailing Address Currently on Record
*Physical Address Currently on Record
Street/PO Box
Apt #
Street
Apt #
City
State
Zip Code
City
State
Zip Code
Country (if not USA)
Postal Code (if not USA)
Country (if not USA)
Postal Code (if not USA)
New Mailing Address or
check if unchanged
New Physical Address or
check if unchanged
Street/PO Box
Apt #
Street
Apt #
City
State
Zip Code
City
State
Zip Code
Country (if not USA)
Postal Code (if not USA)
Country (if not USA)
Postal Code (if not USA)
Apply Changes to the Following Applications
First Name
MI
Last Name
Social Security Number
Date of Birth (MM/DD/YY)
First Name
MI
Last Name
Social Security Number
Date of Birth (MM/DD/YY)
First Name
MI
Last Name
Social Security Number
Date of Birth (MM/DD/YY)
First Name
MI
Last Name
Social Security Number
Date of Birth (MM/DD/YY)
First Name
MI
Last Name
Social Security Number
Date of Birth (MM/DD/YY)
I certify that I am authorized to change the address of the person(s) listed above. If applicant is a child, the adult who sponsored the
application must sign. If signing on behalf of another adult, provide proof of legal authority to sign on their behalf. Unauthorized
requests will not be processed.
Adult Signature
Date
Daytime Telephone Number
Printed name of the person who signed
Social Security Number
Date of Birth
SIGNATURE IS
Adult Signature
Date
Daytime Telephone Number
REQUIRED FOR
Printed name of the person who signed
Social Security Number
Date of Birth
ALL ADULTS 18
AND OVER
Adult Signature
Date
Daytime Telephone Number
Printed Name of the person who signed
Social Security Number
Date of Birth
Phone 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
04414
Page 1 of 2
Confidential
04414 (Rev. 09/14)
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