2005 Child Application Form - Alaska Department Of Revenue Page 2
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204076
CHILD’S NAME (First, MI, Last)
Read Each Question Carefully.
Answer questions 8-12 if you answered YES to questions 4A or 4B.
8. If this child left Alaska before January 1, 2004, enter the date the child actually departed. List all dates this child was absent from Alaska in 2004
through the date of this application. If the child is still absent, leave the end date blank. For each type of absence, write the absence reason code
in the space provided and list the dates on separate lines. (See Pages 23 and 24 for instructions). All absence reason codes are explained below.
If this child had more absences than the number of lines provided below, use the Additional Absences Form on Page 31.
Code
Absence Begin Date
Absence End date
(A-Q)
Month / Day / Year
Month / Day / Year
Why was this child absent?
Absence Codes (see Page 23)
Answer question 13 if you answered NO to questions 1 or 3.
A. Accompanied an eligible adult Alaska resident.
13A. Print this child’s name as it appears on this child’s birth certificate.
First Name
M.I.
Last Name
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 at
U.S. Birth State
Country of Birth (If not U.S.)
See Q for secondary education.
D. Received continuous medical treatment under a physician’s
care. Attach physician’s statement.
Date Child’s Most Recent
Alaska Residency Began
I.
Vacationed.
Your Relationship to Child
Month
Day
Year
K. Other reasons, including business. Attach explanation.
L. Cared for a parent, spouse, sibling, child or stepchild with a
13B. Other Parent or Adult if in the Same Household
critical life-threatening illness that required the ill individual to
leave Alaska for treatment.
First Name
M.I. Last Name
N. Provided care for a terminally ill family member. See page 9.
O. As part of a legal custody agreement. Attach a copy of the
Social Security Number
Date of Birth
agreement in effect during calendar year 2004.
Q. Enrolled and attended school as a full-time student receiving
Relationship to Child
secondary education (grades 7 through 12). You may
download our Education Verification form from our web site at
See B for postsecondary education.
If you are not an adult relative of this child, attach an explanation.
9. Was this child out of state with a person other than your-
YES NO
Answer question 14 if you answered NO to question 2.
self? If YES, name that person below.
14A. Person who had physical custody of child for a majority of 2004.
Full Name of Person
Relationship to Child
Full Name of Person
Relationship to Child
Mailing Address
Date of Birth
Social Security Number
Mailing Address
City, State, Zip Code
Daytime Phone #
Daytime Phone Number
City, State, Zip Code
10. Was the person listed in Question 9 an Alaska resident
YES NO
for all of 2004? Skip this question if question 9 was left
Attach an explanation of why you are filing for this child.
blank.
YES NO
Answer questions 11 and 12 if you answered NO to question 3
14B. Was this person an Alaska resident for all of 2004?
or YES to questions 4A or 4B.
Answer questions 15 and 16 if you answered NO to question 5.
11. Was this child born to or adopted by you during 2003 or
YES NO
15.
What is this child’s alien registration number?
2004? If adopted, attach complete copy of adoption papers.
-
A
12. Was this child in Alaska for at least 72 consecutive hours
YES NO
during 2003 or 2004?
16.
What was this child’s legal immigration status on December 31, 2003?
If YES, when was this child most recently in Alaska?
Resident
Asylee
2003
2004
Attach documentation showing
this child was in Alaska.
Refugee
Other (Attach explanation)
If this is the first time you are applying for a dividend for this child,
attach a copy of the front and back of this child’s visa or alien
registration card.
Web site:
04076
Mail this application to: Alaska Department of Revenue, PO Box 110462, Juneau, AK 99811-0462
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