08155 Audit Form 2010.indd
08155
Alaska Permanent Fund Dividend
2010 Audit Form SOCIAL SECURITY NUMBER
DATE OF BIRTH
FIRST NAME
M.I.
Month
LAST NAME
Day
Year
I certify that the information I am supplying on and with this form is true as of the date of my original application. I understand that a false statement made on or with this form will subject me to the same penalties disclosed on my original application.
(Your signature is required)
Date
Questions 1-3 intentionally excluded
4. A. Were you absent from or living outside of Alaska when you filed your application?
No If NO, go to Question 5A
Yes
B. If YES, are you returning to Alaska to remain indefinitely? Yes No C. If YES, when did you depart Alaska? AND when are you returning to remain indefinitely? Month
Day
Year Month Day If NO, go to question 6 Yes No B. If you are married, is your spouse applying for this year's dividend?
5. A. Are you married?
Year
6. A. Have you maintained your principal home or stored the majority of your household belongings in Alaska continuously since December 31, 2008?
Yes
No If NO, attach an explanation
Yes
No
Own Live with parents Other (attach explanation) Lease or Rent B. Do you Store C. Physical address of home or storage: _______________________________________________________________________________________________ CITY:______________________________________ STATE: _________________ ZIP CODE: _________________
7. At any time since DECEMBER 31, 2008 have you: A. Maintained your principal home outside of Alaska?
A.
Yes
No
B.
Yes
No
C. While living in Alaska, registered a vehicle as the owner or co-owner and claimed a non-resident Alaska C.
Yes
No
Did you:
Own
Lease or Rent
Live with parents
Other (attach explanation)
Address City, State, Zip Code
State
B. Claimed residency in another state or country in your employment records, including leave and earnings statements if you are a member of the U.S. Armed Forces?
Vehicle Plate #
motor vehicle tax exemption?
State
D. Accepted full-time permanent employment in another state or country?
D.
Yes
No
E. Filed or you will be required to file a 2009 resident or part-year resident income, personal property, or
E.
Yes
No
Claimed a homestead property tax exemption in another state or country? If YES, attach an explanation F. and copy of the homestead exemption law.
Yes
No
excise tax return in another state or country? If YES, attach a copy of the return.
F.
G. Applied for or received a student loan from another state or country? If YES, attach a copy of
G.
Yes
No
H. Disclosed in a court proceeding or affidavit that you are a resident of another state or country?
H.
Yes
No
I.
I.
Yes
No
L.
Yes
No
the application. If you received a federal Stafford, Sallie Mae, Nellie Mae or Bank loan, answer NO. If YES, attach a copy of the affidavit or documents.
Executed a will which described residency in another state or country? If YES, attach a copy of the will.
L. Moved from Alaska and claimed or will claim moving expenses as a deduction on your 2009 federal income tax return? If YES, attach a copy of the return.
M. Registered to vote in another state or country?
M.
Yes
No
N. Voted in a local or state election in another state or country?
N.
Yes
No
O. Purchased a resident hunting, fishing or trapping license in another state or country? If YES,
O.
Yes
No
P.
P.
Yes
No
Q. Obtained benefits as a result of establishing or maintaining a claim of residency in another state or
Q.
Yes
No
R. Maintained a vehicle registered in another state or country or obtained or renewed another
R.
Yes
No
S. Maintained a driver’s license in another state or country or obtained or renewed another state’s or
S.
Yes
No
attach a copy of that state’s or country’s license regulations.
Filed for divorce, dissolution or legal separation in another state or country? If YES, attach a copy of documents. country? If YES, attach an explanation.
state's or country's vehicle registration?
country’s driver’s license?
08155
Confidential www.pfd.alaska.gov PO Box 110462, Juneau, AK 99811-0462
State State
County
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Vehicle Plate #
State
License #
Alaska Permanent Fund Dividend
2010 Audit Form SOCIAL SECURITY NUMBER
DATE OF BIRTH
FIRST NAME
M.I.
Month
LAST NAME
Day
Year
I certify that the information I am supplying on and with this form is true as of the date of my original application. I understand that a false statement made on or with this form will subject me to the same penalties disclosed on my original application.
(Your signature is required)
Date
Questions 1-3 intentionally excluded
4. A. Were you absent from or living outside of Alaska when you filed your application?
No If NO, go to Question 5A
Yes
B. If YES, are you returning to Alaska to remain indefinitely? Yes No C. If YES, when did you depart Alaska? AND when are you returning to remain indefinitely? Month
Day
Year Month Day If NO, go to question 6 Yes No B. If you are married, is your spouse applying for this year's dividend?
5. A. Are you married?
Year
6. A. Have you maintained your principal home or stored the majority of your household belongings in Alaska continuously since December 31, 2008?
Yes
No If NO, attach an explanation
Yes
No
Own Live with parents Other (attach explanation) Lease or Rent B. Do you Store C. Physical address of home or storage: _______________________________________________________________________________________________ CITY:______________________________________ STATE: _________________ ZIP CODE: _________________
7. At any time since DECEMBER 31, 2008 have you: A. Maintained your principal home outside of Alaska?
A.
Yes
No
B.
Yes
No
C. While living in Alaska, registered a vehicle as the owner or co-owner and claimed a non-resident Alaska C.
Yes
No
Did you:
Own
Lease or Rent
Live with parents
Other (attach explanation)
Address City, State, Zip Code
State
B. Claimed residency in another state or country in your employment records, including leave and earnings statements if you are a member of the U.S. Armed Forces?
Vehicle Plate #
motor vehicle tax exemption?
State
D. Accepted full-time permanent employment in another state or country?
D.
Yes
No
E. Filed or you will be required to file a 2009 resident or part-year resident income, personal property, or
E.
Yes
No
Claimed a homestead property tax exemption in another state or country? If YES, attach an explanation F. and copy of the homestead exemption law.
Yes
No
excise tax return in another state or country? If YES, attach a copy of the return.
F.
G. Applied for or received a student loan from another state or country? If YES, attach a copy of
G.
Yes
No
H. Disclosed in a court proceeding or affidavit that you are a resident of another state or country?
H.
Yes
No
I.
I.
Yes
No
L.
Yes
No
the application. If you received a federal Stafford, Sallie Mae, Nellie Mae or Bank loan, answer NO. If YES, attach a copy of the affidavit or documents.
Executed a will which described residency in another state or country? If YES, attach a copy of the will.
L. Moved from Alaska and claimed or will claim moving expenses as a deduction on your 2009 federal income tax return? If YES, attach a copy of the return.
M. Registered to vote in another state or country?
M.
Yes
No
N. Voted in a local or state election in another state or country?
N.
Yes
No
O. Purchased a resident hunting, fishing or trapping license in another state or country? If YES,
O.
Yes
No
P.
P.
Yes
No
Q. Obtained benefits as a result of establishing or maintaining a claim of residency in another state or
Q.
Yes
No
R. Maintained a vehicle registered in another state or country or obtained or renewed another
R.
Yes
No
S. Maintained a driver’s license in another state or country or obtained or renewed another state’s or
S.
Yes
No
attach a copy of that state’s or country’s license regulations.
Filed for divorce, dissolution or legal separation in another state or country? If YES, attach a copy of documents. country? If YES, attach an explanation.
state's or country's vehicle registration?
country’s driver’s license?
08155
Confidential www.pfd.alaska.gov PO Box 110462, Juneau, AK 99811-0462
State State
County
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Date
State
Vehicle Plate #
State
License #
