2005 Application On Behalf Of Another Adult Form - Alaska Department Of Revenue Page 2
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204078
NAME (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 applicant left before January 1, 2004, enter the date the applicant actually departed. List all dates the applicant was absent from Alaska in 2004
through the date of this application. If the applicant 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 the applicant had more absences than the number of lines
provided below, you may download the Additional Absences Form from our web site.
Code
Absence Begin Date
Absence End Date
Why was the applicant absent?
(A-Q)
Month - Day - Year
Month - Day - Year
Absence Codes
Answer questions 9 and 10 if you answered YES to 3B.
YES NO
A. Accompanied an eligible Alaska resident as the resident’s
9. Has the applicant ever lived in Alaska as a resident for
spouse.
at least 180 days ? If YES, list the dates of the most
recent 180 day period.
Spouse’s First Name
M.I. Spouse’s Last Name
From (Month-Day-Year)
Through (Month-Day-Year)
Spouse’s Social Security Number
Spouse’s Date of Birth
10.Was the applicant in Alaska for at least 72 consecutive
YES NO
hours during 2003 or 2004?
B. Enrolled and attended school as a full-time student receiving
If YES, when was the applicant most recently in Alaska?
postsecondary education (beyond grade 12). You may
2003
2004
Attach documentation showing the applicant
download our Education Verification form from our web site.
was in Alaska.
See Q for secondary education.
Answer question 11 if you answered NO to question 1.
C. Served as a member of the U.S. Armed Forces. Attach a
copy of the applicant's orders.
11.
Print the applicant's name as it appears on the birth certificate.
First Name
M.I.
Last Name
D. Received continuous medical treatment under a physician’s
care. Attach physician’s statement.
E. Served as a member of Alaska’s congressional delegation or
U.S. Birth State
Country of Birth (If not U.S.)
staff.
H. As a requirement of employment by the State of Alaska.
If married, print spouse’s name.
First Name
M.I.
Last Name
I. Vacationed.
J. Sought employment or was employed for a reason other
Spouse’s Social Security Number
than B, C, E, H or Q. Attach explanation.
K. Other reasons, including business. Attach explanation.
Spouse’s Date of Birth (Month-Day-Year)
L. Cared for a parent, spouse, sibling, child or stepchild with a
critical life-threatening illness that required the ill individual
to leave Alaska for treatment.
Answer questions 12 & 13 if you answered NO to question 4.
M. Settled the estate of a deceased parent, spouse, sibling,
12. What is the applicant's alien registration number?
child or stepchild.
A-
N. Provided care for a terminally ill family member.
13. What was the applicant's immigration status on December 31, 2003?
P. Employed aboard a vessel of the U.S. Merchant Marine.
Resident
Asylee
Q. Enrolled and attended school as a full-time student receiving
secondary education (grades 7 through 12). You may
Refugee
Other (Attach explanation)
download our Education Verification form from our web site.
If this is the first time the applicant is applying for a dividend, attach a
See B for postsecondary education.
copy of the front and back of his/her visa or alien registration card.
Web site:
Mail this application to:
04078
Alaska Department of Revenue, PO Box 110462, Juneau, AK 99811-0462
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