Form 14305 - Direct Deposit Form May 2014
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1
2Alaska Department of Revenue
14305
PFD Division Use Only
PFD ALN:
Permanent Fund Dividend Division
Direct Deposit Form
Use this form after you have submitted your PFD application and want to add, change, or withdraw your direct deposit information. The PFD
Division will apply this direct deposit change to current year records only. Requests with incomplete or incorrect information will not be
processed.
Has your address changed since you applied for the dividend? If so, please submit our Address Change Form. You can obtain this form
at our website at , or at one of the Division offices.
Select one of the following options and follow the instructions
WITHDRAW
ADD
CHANGE
If adding direct deposit information,
If withdrawing from direct deposit,
If changing direct deposit information,
complete sections B, C and D.
complete sections A, C and D.
complete sections A, B, C and D.
Section A: Enter previously submitted financial account information (An answer is required for each field)
Enter the Account Number
Enter the Financial Institution Name
If you do not know the direct deposit account currently on file, you must complete section E OR section F on the second page.
Section B: Enter new financial account information (An answer is required for each field)
Enter the Financial Institution Name
Enter the Financial Institution Routing Number
Enter the Account Number
Savings
Checking
OR
Both
Child’s
Sponsor’s
OR
OR
If adding or changing a child’s account, check the box to indicate whose name is on the account.
Section C: Apply the changes to each of the following applicants
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)
Section D: Signature (All adults listed above must sign below. If a child is listed above, the sponsor must sign below.)
By signing below, I authorize the Permanent Fund Dividend Division to make the changes listed above.
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
ALL ADULTS 18
Printed name of the person who signed
Social Security Number
Date of Birth
AND OVER
Adult Signature
Date
Daytime Telephone Number
Printed name of the person who signed
Social Security Number
Date of Birth
Send this completed form to: Permanent Fund Dividend Division, PO Box 110462, Juneau, AK 99811-0462
14305
Phone (907) 465-2326
Fax (907) 465-3470
Form 14305 (Rev. 5/14)
Confidential
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