Permanent Fund Dividend Application Internet Filing Signature -Alaska Department Of Revenue - Permanent Fund Dividend Division Form 2001

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Signature Page (Child)
Alaska Department of Revenue
Permanent Fund Dividend Division
2001 Permanent Fund Dividend Application
Internet Filing Signature Form
Complete the following:
Child’s SSN: ______________________ Date of Birth: ________________________
Child’s Name: __________________________________________
Address: ______________________________________________
City: _______________________
State: _________ Zip: _______________ Country (if not USA): __________________________
Daytime Telephone Number: ___________________________
I certify that the minor for whom I am applying:
• Is now and will remain an Alaska resident indefinitely.
• Unless born to or adopted by an Alaska resident after December 31, 1998, was an Alaska resident for
all of 2000 and was in the state of Alaska for at least 72 consecutive hours in 1999 or 2000.
I understand that if what I say isn’t true, it’s a criminal offense and if I am convicted, in addition to
any criminal penalties:
• I will lose this and all future dividends.
• I must pay back all dividends I have been paid or that I have claimed on behalf of this child.
I understand that if I deliberately misrepresent or recklessly disregard a fact, I am liable for civil
penalties:
• I will lose this dividend and the next five dividends.
• I may have to pay a fine of up to $5,000.
I authorize the Alaska Department of Revenue to obtain information to verify my eligibility or the
eligibility of any child I sponsor. I authorize the Social Security Administration to release any
information regarding the child’s identity to the Department of Revenue. I agree that a copy of this
authorization is as valid as the original.
I certify that the information I submitted electronically is true and correct.
Sponsor’s Signature
Date
Mail this signed and dated form to:
Department of Revenue Use Only
Alaska Department of Revenue
Permanent Fund Dividend Division
PO Box 110462
Juneau, AK 99811-0462
Filing Deadline: April 2, 2001
04-100C-sig New 12/00

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