Form 04-100 B - Application On Behalf Of Another Adult - 2004 Page 2
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1
2Name (First, MI, Last)
Read Each Question Carefully.
Answer question 8 if you answered NO to question 2 or YES to questions 3A or 3B.
8.
If the adult left before January 1, 2003, enter the date he or she actually departed. List all dates they were absent from Alaska
in 2003 through the date of this application. If the adult is still absent, leave the end date blank. For each type of absence,
write the absence code in the space provided and list the dates on separate lines. All absence codes are detailed below. If
you have more absences than the number of lines provided below, use Additional Absences Form or attach additional sheets as
needed and use the format below.
Code
Absence Begin Date
Absence End Date
Why was the adult absent?
(A-Q)
Month - Day - Year
Month - Day - Year
Answer questions 9 and 10 if you answered YES to 3B.
Absence Codes
YES NO
9.
Has the adult ever lived in Alaska as a resident for at
least 180 days ? If YES, list the dates of the most recent
180 day period.
A.
Accompanied an eligible Alaska resident as the resident’s
spouse.
From (Month-Day-Year)
Through (Month-Day-Year)
Spouse’s First Name
M.I. Spouse’s Last Name
YES NO
Was the adult in Alaska for at least 72 consecutive hours
during 2002 or 2003?
Spouse’s Social Security Number
Spouse’s Date of Birth
10.
If YES, when was the adult most recently in Alaska?
2003
2002
Attach documentation showing
the adult was in Alaska if
absent more than 300 days.
B.
Enrolled and attended school as a full-time student receiving
postsecondary education (beyond grade 12). You may
download our Education Verification form from our web site.
11.
Answer question 11 if you answered NO to question 1.
See Q for secondary education.
Print the adult's name as it appears on the birth certificate.
C.
Served as a member of the U.S. Armed Forces.
First Name
M.I. Last Name
D.
Received continuous medical treatment under a doctor’s care
(Attach doctor’s statement).
Birth State
Place of Birth (If not U.S.)
E.
Served as a member of Alaska’s congressional delegation or
staff.
If married, print spouse’s name.
H.
As a requirement of employment by the State of Alaska.
First Name
M.I. Last Name
I.
Vacationed.
J.
Sought employment or was employed for a reason other than
Spouse’s Social Security Number
B, C, E, H or Q (Attach explanation).
K.
Other reasons, including business (Attach explanation).
L.
Cared for a parent, spouse, sibling, child or stepchild with a
Answer questions 12 & 13 if you answered NO to question 4.
critical life-threatening illness that required the ill individual
12.
What is the adult's alien registration number?
to leave Alaska for treatment.
A-
M .
Settled the estate of a deceased parent, spouse, sibling, child
or stepchild.
What was the adult's immigration status on December 31, 2002?
13.
N.
Provided care for a terminally ill family member.
Resident
Asylee
Refugee
Other (Attach explanation)
P.
Employed aboard a vessel of the U.S. Merchant Marine.
If this is the first time the adult is applying for a dividend, attach a
Q.
Enrolled and attended school as a full-time student
copy of the front and back of the visa or alien registration card.
receiving secondary education (grades 7 through 12).
You may download our Education Verification form
from our web site. See B for postsecondary education.
Mail this application to: Alaska Department of Revenue, PO Box 110462, Juneau, AK 99811-0462
04-100 B Back (12/03)
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