Adult Application - Alaska Department Of Revenue - 2005
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204071
Alaska Permanent Fund Dividend
A
2005 Adult Application
(Adults 18 and older on date of application)
_____/___/_______
____/____/______
MALE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
Under federal law you must provide your SSN.
Month
Day
Year
FEMALE
FIRST NAME
M.I. LAST NAME
MAILING ADDRESS
APT #
CITY
STATE
ZIP CODE
PHYSICAL ADDRESS
APT #
CITY
STATE
ZIP CODE
(Write "Same" if same as mailing address)
DAYTIME TELEPHONE
MESSAGE TELEPHONE
E-MAIL ADDRESS (optional)
(
)
-
(
)
-
Shade circles like this:
Not like this:
Provide names, addresses and telephone numbers of two
1. Did you receive a 2004 dividend? Answer YES even if
YES
NO
adult Alaska residents who can verify your residency.
your dividend was assigned or garnisheed. If NO,
VERIFIERS’ SIGNATURES NOT REQUIRED
complete Question 11 on the back of this form AND
Full Name
complete the Adult Supplemental Schedule. Attach the
Supplemental Schedule to this completed application.
Mailing Address
2. Are you in Alaska today? If NO, complete Question 8 on
YES
NO
City, State, Zip Code
the back of this form and Parts B & C of the Adult
Supplemental Schedule and attach it to this completed
Daytime Phone #
Social Security # (optional)
application.
3. A. During 2004, were you gone from Alaska more
YES
NO
Full Name
than 90 days total?
Mailing Address
If YES, complete Question 8 on the back of this
form AND Parts B & C of the Adult Supplemental
City, State, Zip Code
Schedule and attach it to this completed application.
Daytime Phone #
Social Security # (optional)
B. During 2004, were you gone from Alaska more
YES
NO
than 180 days total?
Read the Following Statements and Sign Below
If YES, complete Questions 8 through 10 on the
back of this form AND Parts B & C of the Adult
I certify that:
Supplemental Schedule and attach it to this
• I am now and intend to remain an Alaska resident indefinitely.
completed application.
• I was an Alaska resident for all of 2004.
• I have not claimed residency in another state.
Failure to disclose absences may result in the denial
• I was in the state of Alaska for at least 72 consecutive hours in
of your application.
2003 or 2004.
I understand that if what I say is not true, it is a criminal offense and
4. Are you a United States citizen? If NO, complete
YES
NO
if I am convicted, in addition to any criminal penalties:
Questions 12 and 13 on the back of this form.
• I will lose this and all future dividends.
YES
NO
5. At any time since December 31, 2003, were you on active
• I will be required to pay back all dividends I have been paid.
duty as a member of the U.S. Armed Forces?
I understand that if I deliberately misrepresent or recklessly
Civilians, Alaska National Guard members and Alaska
disregard a fact, I am liable for civil penalties:
Reservists, Answer NO.
• I could lose this dividend and my next five dividends.
• I may have to pay a fine of up to $5,000.
UA COLLEGE SAVINGS PLAN
6.
YES
NO
Do you want to place 50% of your dividend in the UA
By submitting this application I am consenting to registration with
College Savings Plan? See page 35 for a description
the U.S. Selective Service System, if so required by law.
of the plan.
Release of Information: I authorize the Alaska Department of Revenue
DIRECT DEPOSIT PROGRAM
to obtain confidential information necessary to verify my eligibility. I
7.
YES
NO
authorize the release of confidential records necessary to verify my
Do you want your dividend deposited directly into your
eligibility from any public agency including the Social Security
bank account? If YES, deposit into:
Administration; Internal Revenue Service; Alaska Department of Health
Same account as last year
OR
New account listed below
and Social Services, Division of Public Assistance and Office of
Children’s Services. I agree that a copy of this authorization is as valid as
NEW ACCOUNTS ONLY, fill in information below. See page 5 for instructions.
the original.
Account Type
Bank
Savings
Code
(Select one)
Checking
I certify that the information I am supplying on and with this form is
true and correct.
New Account Number
Your Signature
Date
-
Filing Deadline: Your application must be received by the
04071
Dividend Division or postmarked by March 31, 2005.
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