Bbedc Affidavit Of Residency Form

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BBEDC Affidavit of Residency Form
Name:
Date:
Phone:
Fax:
Physical Address:
PO Box
City/State:
Zip:
How long at this address?
The Bristol Bay Economic Development Corporation requires that anyone seeking services from BBEDC is a resident of
one of the 17 Bristol Bay CDQ communities. (Aleknagik; Clarks Point; Dillingham; Egegik; Ekuk; Ekwok; King Salmon;
Levelock; Manokotak; Naknek; Pilot Point; Port Heiden; Portage Creek; South Naknek; Togiak; Twin Hills; Ugashik)
Definition of a CDQ community resident: A person who has resided (lived) in any of the 17 CDQ communities for a period
of 12 consecutive months or more immediately prior to application and continues to live in a CDQ community. Absences
for up to 60 consecutive days per year are allowable. Incarceration does not disqualify an individual from program
eligibility; however, incarceration for more than 60 days is an inexcusable absence. The residency of any person under
the age of 18 years shall be the same as the residency of the adult(s) who claim that person as a dependent on their
federal tax return. Residency must be renewed annually.
In order to verify residency in one of the 17 CDQ communities you must provide the following documentation showing
your name & current address (ID and additional document address must match):
 A copy of your government issued photo ID (Example: AK Drivers License/ID card, Military or Tribal ID card) AND a copy of
at least one of the following documents:
Alaska Permanent Fund Dividend records (https://pfd.alaska.gov)
Current rent receipt, electric/fuel bill or other proof of maintaining a home in a BBEDC CDQ community
Most recent employment or unemployment records (ex. W-2, check stub, statement)
Recent TANF, Food Stamp benefit award letter, or BBNA Heating Assistance approval letter
Current ADF&G commercial/sport fishing or hunting license (limited entry permit card will not be accepted)
If you are out of the CDQ community for more than 60 consecutive days, the only excusable absences are: post-secondary
purposes; military service; participation in BBEDC Employment & Training Programs; medical reasons; serving as member of
Alaska Senate, Alaska House of Representatives or staff of any such official; or participating in a required academic internship
that cannot be accomplished in-region. To waive the 60-day requirement you must supply one of the following:
School enrollment form or transcripts verifying full-time attendance during the previous year if you are a student away from home
attending school
Current orders if you are on active military duty
Letter of verification of program participation from BBEDC Employment & Training staff
Letter from your physician stating the reason for the need to reside in another location and the time estimated for the stay
Proof of position in Alaska Senate or Alaska House of Representatives or employment as staff of any such official
Proof of required academic internship and demonstration of inability to obtain the opportunity in-region
By signing this affidavit, I warrant that I am residing full-time in the community from which I am applying and I attest that the
documents submitted are true and accurate to the best of my knowledge. I acknowledge that any falsification or
misrepresentation of the information submitted will result in the termination of benefits and I may be required to pay back any
funds that were provided by BBEDC as a result of the information provided.
SIGNATURE:
DATE:
This form must be signed by an Authorized Representative of the Village Tribal Council or the City Government.
I verify that
is a resident of
, and
□ has been
□ has not been (Reason:
_____) residing in this CDQ community for the
□ Residency unknown to authorized signer
past twelve months.
PRINT NAME: _______________________________SIGNATURE:
ORGANIZATION:
DATE:
Thank you for your assistance. If you have any questions, please call BBEDC at 842-4370 or 1-800-478-4370.
Revised 06/2016

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