Form As - Adult Supplemental Schedule - 2013 printable pdf download

04003

Division Requested

Alaska Permanent Fund Dividend

2013 Adult Supplemental Schedule

Supplemental Schedule

THIS IS NOT AN APPLICATION

Answer parts A, B & C if:

Answer only parts B & C if:

• You did not receive a 2012 dividend.

• You were absent from Alaska for more than 90 days during 2012.

• You were outside of Alaska when you ﬁ led your application.

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Month

Day

Year

FIRST NAME

M.I. LAST NAME

I certify that the information I am supplying on and with this form is true. I understand that a false statement made on or with this form will

subject me to the same penalties disclosed on my original application.

Date

Your signature is required

Part A

1. When did your most recent Alaska residency begin? This means the month, day and year you arrived in Alaska

with the intent to remain indeﬁ nitely. It may be the day you were born in Alaska. If you skipped a year in applying,

attach an explanation of why you did not apply last year and include any absences from January 1, 2011 to present.

Month

Day

Year

2. Items A through G represent residency ties to Alaska. All items may not apply to you. If you are applying for the ﬁ rst time or after a break in applying,

you must attach supporting proof or documentation for A, B, C or G. Photocopies of documentation in your name are acceptable. Documentation

will not be returned to you.

A. I moved my household belongings to Alaska in: .................................................Month __________ Year __________ (attach documentation)

B. I purchased, leased or rented a place to live in Alaska in: ...................................Month __________ Year __________ (attach documentation)

C. I obtained permanent employment in Alaska in: ..................................................Month __________ Year __________ (attach documentation)

EMPLOYER'S NAME: _____________________________________ EMPLOYER'S DAYTIME TELEPHONE NUMBER: ___________________

EMPLOYER'S ADDRESS: _________________________________________________________________________________________

CITY:____________________________________________ STATE: __________________ ZIP CODE:__________________________

D. I registered to vote in Alaska in: .........................................................................Month __________ Year __________

E. I obtained an Alaska driver's license or ID in: ....................................................Month __________ Year __________ ID/License # __________

F. I registered a vehicle in Alaska in: ......................................................................Month __________ Year __________ Plate ________________

G. Other: _______________________________________________________ Month __________ Year __________

(Public Assistance, Medicaid)

3. If this is the ﬁ rst time you have applied for a dividend since 1988, send your original birth certiﬁ cate or a true certiﬁ ed copy, original passport, or

naturalization papers with this form. WE WILL NOT ACCEPT A PHOTOCOPY OR HOSPITAL CERTIFICATE. Your birth certiﬁ cate, passport or

naturalization papers will be returned if you enclose a self-addressed, stamped envelope.

Part B

Yes

If NO, go to Question 5A

A. Were you absent from or living outside of Alaska when you ﬁ led your application?

B. If YES, are you planning to return to Alaska to stay and make a home at some point in the future?

Yes

No If NO, attach an explanation

C. If YES, when did you depart Alaska? AND when are you returning to stay and make a home?

Month

Day