Form 14815 - Address Change Form (Page 2 of 2) in pdf

Form 14815 - Address Change Form Page 2

Alaska Department of Revenue

Permanent Fund Dividend Division

14815

The information that is currently on the Permanent Fund Dividend record is required. If you do not know the

current address information and are unable to provide picture identification at one of PFD's offices, have your

signature witnessed by a Notary Public below.

Notary

State of __________________

________________________________, being by me duly sworn, personally appeared before me and

Requestor's Name

signed this document.

Requestor's Signature

Subscribed and sworn to before me by ______________________________ this _________ day of

Name

_________________, 20____.

___________________________________________

Notary Public

Notary Seal

: _________________________

My commission expires

PFD Representative

_________________________________________ appeared before me with picture identification.

Requestor's Name

_________________________________________

________________________

Signature of PFD Representative

Date

14815

14815 (Rev. 09/14)

Page 2 of 2

Form 14815 - Address Change Form Page 2