Form 08155 - Audit - Alaska Permanent Fund Dividend - 2011
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108155
Alaska Permanent Fund Dividend
2011 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
YES
NO
If NO, go to question 5A
4.
A. Were you absent from or living outside of Alaska when you fi led your application?
YES
NO
B. If YES, are you returning to Alaska to remain indefi nitely?
C. If YES, when did you depart Alaska? AND when are you returning to remain indefi nitely?
Month
Day
Year
Month
Day
Year
YES
NO
A. Are you married?
If NO, go to question 6
5.
YES
NO
B. 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, 2009?
B. Do you
Own
Lease or Rent
Live with parents
Store
Other (attach explanation)
C. Physical address of home or storage: _____________________________________________________________________________________
CITY:____________________________________ STATE: _________________ ZIP CODE: _________________
7. At any time since DECEMBER 31, 2009 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. Claimed residency in another state or country in your employment records, including leave and
B.
YES
NO
earnings statements if you are a member of the U.S. Armed Forces?
VEHICLE PLATE #
C. While living in Alaska, registered a vehicle as the owner or co-owner and claimed a non-resident
C.
YES
NO
Alaska motor vehicle tax exemption?
STATE
D. Accepted full-time permanent employment in another state or country?
D.
YES
NO
STATE
E. Filed or you will be required to fi le a 2010 resident or part-year resident income, personal
E.
YES
NO
property, or excise tax return in another state or country? If YES, attach a copy of the return.
STATE
COUNTY
F. Claimed a homestead or homeowner's property tax exemption in another state or country? If
F.
YES
NO
YES, attach an explanation and copy of the homestead or homeowner's exemption law.
DATE
STATE
G. Applied for or received a student loan from another state or country? If YES, attach a copy of
YES
NO
G.
the application.
If you received a federal Stafford, Sallie Mae, Nellie Mae or Bank loan, answer NO.
STATE
DATE
H. Disclosed in a court proceeding or affi davit that you are a resident of another state or country?
H.
YES
NO
If YES, attach a copy of the affi davit or documents.
STATE
DATE
I.
Executed a will which described residency in another state or country? If YES, attach a copy
I.
YES
NO
of the will.
DATE
STATE
L. Moved from Alaska and claimed or will claim moving expenses as a deduction on your 2010
YES
NO
L.
federal income tax return? If YES, attach a copy of the return.
DATE
STATE
M. Registered to vote in another state or country?
M.
YES
NO
STATE
DATE
N. Voted in a local or state election in another state or country?
YES
NO
N.
STATE
DATE
O. Purchased a resident hunting, fi shing or trapping license in another state or country? If YES,
O.
YES
NO
attach a copy of that state’s or country’s license regulations.
STATE
DATE
P. Filed for divorce, dissolution or legal separation in another state or country? If YES, attach
YES
NO
P.
a copy of documents.
STATE
DATE
Q.
YES
NO
Q. Obtained benefi ts as a result of establishing or maintaining a claim of residency in another state
or country? If YES, attach an explanation.
VEHICLE PLATE #
STATE
R. Maintained a vehicle registered in another state or country or obtained or renewed another
R.
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
S.
YES
NO
or country’s driver’s license?
Confi dential
08155
PO Box 110462, Juneau, AK 99811-0462
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