Education Verification Form - Alaska Department Of Revenue - 2000
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1Alaska Department of Revenue
Permanent Fund Dividend
Education Verification Form
For Calendar Year 2000
Students
Send a separate Education Verification Form for each school you enrolled in and attended during calendar
year 2000. 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 2000.
Check Enrollment
Check Type of Tuition Paid
Dates Student Enrolled and Attended
Status
Non-
No
During Calendar Year 2000.
Resident
Part Time
Full Time
Resident
distinction
/
/2000
/
/2000
through
/
/2000
/
/2000
through
/
/2000
/
/2000
through
/
/2000
/
/2000
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 where your institution is located?
b. If no, please explain below and attach copies of your resident tuition requirements.
Yes
No
2. Is this institution accredited by a regional accreditation association?
If Yes , this institution is accedited by:
Signature of Registrar
Date
Registrar’s Seal
Name of Your Institution
Telephone Number
Mailing Address of Your Institution
City
State
Zip Code
Send completed form to:
Alaska Department of Revenue
Permanent Fund Dividend Division
PO Box 110462
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