Form 04-100a - Adult Application - Alaska Permanent Fund Dividend - 1998
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1
2Alaska Permanent Fund Dividend
1998
Adult Application
A
You may photocopy this form
Office Use Only
I M P O R T A N T
Read This Statement and Sign Box 12 Below
Have you been an Alaska resident
12. Read this statement carefully and sign below. Don’t change anything. If
since December 31, 1996?
you do, we must deny your application.
Do you intend to remain an Alaska
I certify that:
resident indefinitely?
• I am now and intend to remain an Alaska resident.
• I was an Alaska resident for all of 1997.
If you answered “NO” to either of the above questions, please stop.
• I have been in the state in 1996 or 1997.
You are not eligible for the 1998 dividend and should not apply.
• I haven’t claimed residency in another state.
I understand that if what I say isn’t true, it’s a criminal offense and if
Federal law makes it mandatory that you
1. Your Social Security Number (SSN)
I am convicted, in addition to any criminal penalties:
provide your SSN. If we have it on file from a
• I will lose this dividend.
previous year, we are required to provide it to
the IRS.
• I will lose future dividends.
• I must pay back all dividends I have been paid.
2. Your Date of Birth
3. Telephone Number
Month
Day
Birth Year
Daytime
(
)
I understand that if I deliberately misrepresent or recklessly disregard
Message (
)
a fact, I am liable for civil penalties:
4. Your First Name
M.I.
Last Name
• I will lose this dividend.
• I will lose my next 5 dividends.
• I may have to pay a fine of up to $5,000.
Your Mailing Address
I authorize the Alaska Department of Revenue to get information to verify
my eligibility. I authorize the Social Security Administration to release to
the Alaska Department of Revenue, any information they have regarding
City
State
Zip Code
my identity and SSN. I agree a copy of this authorization is as valid as the
original.
12. Signature
Date
Yes
No
5.
Did you receive a 1997 dividend? Answer YES if you
received your dividend or it was assigned or garnished. If
Get Two Adults Who Know You to Read and Sign Below
NO, complete the front of this application as well as
questions 14 through 18 on the back of this form and
13. I certify that:
complete the entire 1998 Adult Supplemental Schedule
• I understand the eligibility requirements of the PFD program.
and attach it to this completed application.
• The adult named on this application was an Alaska resident for all
Yes
No
of 1997.
6. Are you in Alaska today? If NO, answer Questions 19-
21C on the back of this form AND complete the entire 1998
• The adult is still an Alaska resident.
Adult Supplemental Schedule and attach it to this
completed application.
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 penalities:
7. Failure to disclose reportable absences may result in the
• I will lose future dividends.
denial of your application.
• I must pay back all dividends I have been paid.
During 1997, were you gone from Alaska for more than:
I understand that if I deliberately misrepresent or recklessly disregard
a fact regarding the applicant listed on this application, I am liable for
A. 90 days total?
Yes
No
civil penalties:
If YES, complete Questions 19-21C on the back of this
• I will lose my next five dividends.
form AND complete Parts B & C on the 1998 Adult
• I may have to pay a fine up to $5,000.
Supplemental Schedule and attach it to this completed
application.
I agree to respond to questions asked by the Alaska Department of
Revenue regarding the adult named on this application.
B. 180 days total?
Yes
No
If YES, complete Questions 19-21C on the back of
13A. Signature (Spouse, Relative, or Friend)
Date
this form AND the entire 1998 Adult Supplemental
Schedule and attach it to this completed application.
Yes
No
8. Are you a United States citizen?
If NO, complete
Printed Name
Social Security Number
Questions 22-23 on the back of this form.
Mailing Address
9. At any time since December 31, 1996, have you been on
Yes
No
active duty as a member of the U.S. Uniformed Services
(Armed Forces or the Officers’ Corps of the U.S. Public
City, State, Zip Code
Daytime Phone #
Health Service or the National Oceanic and Atmospheric
Administration)? Answer NO if you were Alaska National
Guard or Alaska Reservist, unless on full-time active duty.
13B. Signature (Spouse, Relative, or Friend)
Date
10.
Check here if you want to place 50% of your dividend in the
Printed Name
Social Security Number
Advance College Tuition program. See page 7 of the instructions
for a description of the program.
Mailing Address
11.
Check here if you want all of your dividend deposited directly into
the same Alaska account as you did last year.
City, State, Zip Code
Daytime Phone #
OR
If your account is different, or you can’t remember where it was deposited last
year, complete ALL of the information below: (see page 9 for instructions)
FILING DEADLINE
Account Number
C
hecking
Code
S
avings
March 31, 1998
S
ecurities
Web Site:
04-100A 1Front (10/97)
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