Form 04-100 B - Application On Behalf Of Another Adult - 2004

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Alaska Permanent Fund Dividend
2004 Application on
B
Use this form if you are applying for another adult
who did not apply for a dividend.
Behalf of Another Adult
Check if you:
A . are the spouse, parent, legal guardian or authorized
B. are the legal guardian or conservator of the adult; or
representative of the disabled adult;
C. hold a power of attorney for the adult.
ATTACH EVIDENCE OF YOUR AUTHORITY TO FILE FOR THIS PERSON.
Date of Birth
Social Security Number
Month
Day
Year
Under federal law you must provide the adult SSN. If we
Male
have it on file from a previous year, we will use it and
provide it to the IRS.
Female
First Name
M.I.
Last Name
Zip Code
Mailing Address
City
State
Zip Code
State
Physical Address (Write "Same" if same as mailing address)
City
Daytime Telephone
Message Telephone
E-mail Address (Optional)
(
)
-
(
)
-
Shade circles like this:
Not like this
Provide the Name, Address and Telephone Number of Another
1.
Did the adult receive a 2003 dividend? Answer YES
Adult Alaska Resident Who Can Verify The Applicant's Residency
Yes
No
even if the adult's dividend was assigned or garnisheed.
(VERIFIERS’ SIGNATURE NOT REQUIRED)
If NO, complete Question 11 on the back of this form
Full Name
SSN (Optional)
AND complete the Adult Supplemental Schedule
and attach it to this completed application.
Mailing Address
2.
Is the adult in Alaska today? If NO, complete Question
Yes
No
8 on the back of this form and Parts B & C on the
City, State, Zip Code
Daytime Telephone Number
Adult Supplemental Schedule and attach it to this
(
)
completed application.
Yes
No
3.
A. During 2003, was the adult gone from Alaska
Read the Following Statements and Sign Below
for a total fo 90 days or more?
I certify that the adult named on this application:
• Is now and intends to remain an Alaska resident indefinitely.
If YES, complete Question 8 on the back of this
• Was an Alaska resident for all of 2003.
form AND Parts B & C, on the Adult
• Has not claimed residency in another state.
Supplemental Schedule and attach it to this
• Has been in the state of Alaska for at least 72 consecutive hours in
completed application.
2002 or 2003.
Yes
No
B. During 2003, was the adult gone from Alaska for
I understand that if what I say is not true, it is a criminal offense
more than 180 days total?
and if I am convicted, in addition to any criminal penalties:
• I will lose this and all future dividends.
If YES, complete Questions 8 through 10 on the
• I will be required to pay back all dividends I have been paid.
back of this form AND Parts B & C of the Adult
Supplemental Schedule and attach it to this
I understand that if I deliberately misrepresent or recklessly
completed application.
disregard a fact, I am liable for civil penalties:
Failure to disclose absence may result in the
• I may lose this dividend and my next five dividends.
denial of this application.
• I may have to pay a fine of up to $5,000.
4.
Is the adult a United States citizen? If NO, complete
Yes
No
Release of Information: I authorize the Alaska Department of Revenue to
Questions 12 and 13 on the back of this form.
obtain confidential information necessary to verify the eligibility. I authorize
the release of confidential records necessary to verify my eligibility from any
5. At any time since December 31, 2002, was the adult on
public agency including Social Security Administration and Alaska
Yes
No
active duty as a member of the U.S. Armed Forces?
Department of Health and Social Services, Division of Public Assistance and
Civilians, Alaska National Guard members and Alaska
Office of Children's Services. I agree that a copy of this authorization is as
Reservists, answer NO.
valid as the original.
I certify that the information I am supplying on and with this form is
Yes
No
6. Does the adult want to place 50% of their dividend in
true and correct.
the UA College Savings Plan?
Signature
Date
Number 7 intentionally not used.
Note:
If the adult applicant above is not disabled or
Full Name
Daytime Telephone Number
incompetent, he or she must sign a Residency Verification
(
)
form (Form 74) before this dividend application will be
processed.
Mailing Address
Filing Deadline: March 31, 2004
City, State, Zip Code
SSN (Optional)
web site:
04-100 B Front (12/03)
Office Use Only

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