2005 Child Application Form - Alaska Department Of Revenue
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204075
Alaska Permanent Fund Dividend
C
2005 Child Application
(Persons under 18 years of age on date of application)
If you are 18 years or older or emancipated, use the Adult Application form.
_____/___/_______
____/____/______
MALE
CHILD’S SOCIAL SECURITY NUMBER
CHILD’S DATE OF BIRTH
Under federal law you must provide the child’s SSN.
Month
Day
Year
FEMALE
CHILD’S FIRST NAME
M.I. CHILD’S LAST NAME
ZIP CODE
CHILD’S MAILING ADDRESS
APT #
STATE
CITY
CHILD’S PHYSICAL ADDRESS
APT #
CITY
STATE
ZIP CODE
(Write "Same" if same as mailing address)
Shade circles like this:
Not like this:
Provide the name, address and telephone number of an adult
Alaska resident who can verify this child’s residency.
1. Are you this child’s natural or legally adoptive parent or
YES
NO
VERIFIER’S SIGNATURE NOT REQUIRED
adult relative? If NO, complete Question 13 on the back
of this form AND attach an explanation of why you are
Full Name
filing for this child. (See Page 23)
Mailing Address
2. Has this child lived with you for a majority of 2004 or since
YES
NO
the child’s birth or adoption during 2004? If NO, complete
City, State, Zip Code
Question 14 on the back of this form AND attach an
explanation as to why you are filing for this child.
Daytime Phone #
Social Security # (optional)
3. Did this child receive a 2004 dividend? If NO, complete
YES
NO
Questions 11 through 13 on the back of this form. If this
child was born outside of Alaska and is filing for the first
Sponsor: Read the Following Statements and Sign Below
time, send the following with this application:
• Child’s certified birth certificate or passport.
I certify that the minor for whom I am applying:
• Is now and will remain an Alaska resident indefinitely.
(Not a photocopy or hospital birth certificate)
• Unless born to or adopted by an Alaska resident after December 31,
• Self-addressed stamped envelope for return of
2003, was an Alaska resident for all of 2004 and was in the state of
documents.
Alaska for at least 72 consecutive hours in 2003 or 2004.
4. A. During 2004, was this child gone from Alaska
YES
NO
I understand that if what I say is not true, it is a criminal offense and
more than 90 days total?
if I am convicted, in addition to any criminal penalties:
• I will lose this and all future dividends.
B. During 2004, was this child gone from Alaska
YES
NO
• I will be required to pay back all dividends I have been paid or that I
more than 180 days total?
have claimed on behalf of this child.
If YES to A or B, complete Questions 8
I understand that if I deliberately misrepresent or recklessly
through 12 on the back of this form.
disregard a fact, I am liable for civil penalties:
• I could lose this dividend and the next five dividends.
Failure to disclose absences may result in the denial of
• I may have to pay a fine of up to $5,000.
this application.
Release of Information: I authorize the Alaska Department of Revenue
5. Is this child a United States citizen? If NO, complete
to obtain confidential information necessary to verify my eligibility or the
YES
NO
eligibility of any child I sponsor. I authorize the release of confidential
Questions 15 and 16 on the back of this form.
records necessary to verify my eligibility or the eligibility of any child I
UA COLLEGE SAVINGS PLAN
6.
sponsor from any public agency including the Social Security Administra-
tion; Internal Revenue Service; Alaska Department of Health and Social
Do you want to place 50% of this child’s dividend in the
YES
NO
Services, Division of Public Assistance and Office of Children’s Services.
UA College Savings Plan? See Page 35 for a descrip-
I agree that a copy of this authorization is as valid as the original.
tion of the plan.
I certify that the information I am supplying on and with this form is
DIRECT DEPOSIT PROGRAM
7.
true and correct.
Do you want this child’s dividend directly deposited?
YES
NO
Sponsor’s Signature
Date
-
If YES, deposit into:
Same account as last year
OR
New account listed below
Sponsor’s Social Security Number
Sponsor’s Date of Birth
NEW ACCOUNTS ONLY, fill in information below. See page 5 for instructions.
Bank Code
Account Type (Select one)
Sponsor’s First Name
M.I.
Last Name
Checking
Savings
Name on the account
Child’s
Sponsor’s
Both
New Account Number
Daytime Telephone
E-mail (Optional)
Filing Deadline: This application must be received by the
04075
Dividend Division or postmarked by March 31, 2005.
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