Form 04-077 - Education Verification Form For Calendar Year 2004 - Alaska Department Of Revenue

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04321
Alaska Department of Revenue
Permanent Fund Dividend
Di i i
Education Verification Form
39/52
For Calendar Year 2004
(Internet Downloaded Form)
Students
Send a separate Education Verification Form for each school you enrolled in and attended during calendar
year 2004. You may make copies of this form. Sign the authorization for release of information below.
I authorize release of information regarding my enrollment and tuition to the Alaska Department of
Revenue, Permanent Fund Dividend Division.
Printed Name of Student (Applicant)
Social Security Number
Date of Birth
Signature of Student (Applicant)
Date
Telephone Number
Registrar
Please complete the following information for each semester or quarter that the student was enrolled in and
attended your institution during calendar year 2004.
Check Enrollment
Check Type of Tuition Paid
Dates Student Enrolled and Attended
Status
During Calendar Year 2004.
Part Time
Full Time
Resident
Non-Resident
No distinction
/
/2004
/
/2004
through
/
/2004
/
/2004
through
/
/2004
/
/2004
through
/
/2004
/
/2004
through
1. If you checked Resident under Type of Tuition above, you must answer the following question.
Yes
No
a. Does resident tuition mean that this student is a resident
of the state or country where your institution is located?
b. If no, please attach an explanation and copies of your resident tuition requirements.
2. What is the student's anticipated graduation date (month/Year)? ________/________
3. Check the type of educational program that applies to this student:
Collegiate
Professional Development
Voc-Tech
Secondary
Yes
No
4. Is this institution accredited by a regional accreditation association?
5. Can students who attend this institution qualify for a loan from Nellie Mae or TERI?
6. Is this a Title IV institution?
Signature of Registrar
Date
Registrar's Seal
Printed Name of Registrar
Telephone Number
Name of Your Institution
Mailing Address
City
State
Zip Code
Send completed form to Department of Revenue,
04021
PFD Division, PO Box 110462, Juneau, AK 99811-0462
04-077 E Back (Rev. 11/04)

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