2005 Application On Behalf Of Another Adult Form - Alaska Department Of Revenue
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204077
Alaska Permanent Fund Dividend
2005 Application on
B
Behalf of Another Adult
Use this form if you are applying for another adult who did not apply for a dividend.
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.
_____/___/_______
____/____/______
MALE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
Under federal law you must provide the applicant's SSN.
Month
Day
Year
FEMALE
APPLICANT'S FIRST NAME
M.I. LAST NAME
MAILING ADDRESS
APT #
CITY
STATE
ZIP CODE
ZIP CODE
PHYSICAL ADDRESS
APT #
CITY
STATE
(Write "Same" if same as mailing address)
DAYTIME TELEPHONE
MESSAGE TELEPHONE
E-MAIL ADDRESS (optional)
(
)
-
(
)
-
Provide the name, address and telephone number of an
Shade circles like this:
Not like this
adult Alaska resident who can verify the applicant's residency
1.
Yes
No
Did the applicant receive a 2004 dividend? Answer YES
VERIFIER'S SIGNATURE NOT REQUIRED
even if the adult's dividend was assigned or garnisheed.
Full Name
SSN (Optional)
If NO, complete Question 11 on the back of this form
AND complete the Adult Supplemental Schedule and
attach it to this completed application.
Mailing Address
2.
Is the applicant in Alaska today? If NO, complete
Yes
No
City, State, Zip Code
Daytime Telephone Number
Question 8 on the back of this form and Parts B & C
(
)
on the Adult Supplemental Schedule and attach it to
this completed application.
Read the Following Statements and Sign Below
3.
A. During 2004, was the applicant gone from Alaska
Yes
No
I certify that the adult named on this application:
more than 90 days total?
• Is now and intends to remain an Alaska resident indefinitely.
• Was an Alaska resident for all of 2004.
If YES, complete Question 8 on the back of this form
• Has not claimed residency in another state.
• Has been in the state of Alaska for at least 72 consecutive hours in
AND Parts B & C, on the Adult Supplemental
Schedule and attach it to this completed application.
2003 or 2004.
I understand that if what I say is not true, it is a criminal offense and if I
B. During 2004, was the applicant gone from Alaska
Yes
No
am convicted, in addition to any criminal penalties:
more than 180 days total?
• I will lose this and all future dividends.
• I will be required to pay back all dividends I have been paid.
If YES, complete Questions 8 through 10 on the
back of this form AND Parts B & C of the Adult
I understand that if I deliberately misrepresent or recklessly disregard a
Supplemental Schedule and attach it to this
fact, I am liable for civil penalties:
completed application.
• I may lose this dividend and my next five dividends.
• I may have to pay a fine of up to $5,000.
Failure to disclose absences may result in the
denial of this application.
By submitting this application I am consenting to this applicant's
registration with the U.S. Selective Service System, if so required by law.
4.
Is the applicant a United States citizen? If NO, complete
Yes
No
Questions 12 and 13 on the back of this form.
Release of Information: I authorize the Alaska Department of Revenue to
obtain confidential information necessary to verify the applicant's eligibility. I
5.
At any time since December 31, 2003, was the applicant
Yes
No
authorize the release of confidential records necessary to verify eligibility
on active duty as a member of the U.S. Armed Forces?
from any public agency including the Social Security Administration; Inernal
Civilians, Alaska National Guard members, and Alaska
Revenue Service; Alaska Department of Health and Social Services, Division
Reservists, answer NO.
of Public Assistance and Office of Children's Services. I agree that a copy of
this authorization is as valid as the original.
6.
Does the applicant want to place 50% of their dividend
Yes
No
in the UA College Savings Plan?
I certify that the information I am supplying on and with this form is
true and correct.
Number 7 intentionally not used.
Signature
Date
Note:
If the adult applicant above is not disabled or
incompetent, he or she must sign a Residency Verification
Full Name
Daytime Telephone Number
form (Form 74) before this dividend application will be
(
)
processed.
Mailing Address
City, State, Zip Code
SSN (Optional)
04077
Filing Deadline: March 31, 2005
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