08155 Audit Form 2010

08155 Audit Form 2010

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Alaska Permanent Fund Dividend 081552010 Audit FormSOCIAL SECURITY NUMBER DATE OF BIRTHMonth Day YearFIRST NAME M.I. LAST NAMEI 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) DateQuestions 1-3 intentionally excludedA. Were you absent from or living outside of Alaska when you fi led your application?4. Yes No If NO, go to Question 5AB. If YES, are you returning to Alaska to remain indefi nitely? Yes NoC. If YES, when did you depart Alaska? AND when are you returning to remain indefi nitely?Month Day Year Month Day Year5. A. Are you married? If NO, go to question 6 Yes NoB. If you are married, is your spouse applying for this year's dividend? Yes No If NO, attach an explanationA. Have you maintained your principal home or stored the majority of your6. Yes No household belongings in Alaska continuously since December 31, 2008? B. Do you Own Lease or Rent Live with parents Other (attach explanation)StoreC. Physical address of home or storage: ...

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Alaska Permanent Fund Dividend 2010 Audit Form
SOCIAL SECURITY NUMBER
FIRST NAME
DATE OF BIRTH M.I. LAST NAME YearMonth Day     
08155
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 fi led your application?Yes      No If NO, go to Question 5A B.If YES, are you returning to Alaska to remain indefi nitely?Yes No CIf YES, when did you depart Alaska?.  when are you returning to remain indefi nitely? AND Month Day Year Month Day Year 5.A. Are you married?Y   e  s                 N   o NO, go to question 6 If B. If you are married, is your spouse applying for this year's dividend? Yes       No  If NO, attach an explanation 6.Ayour principal home or stored the majority of your. Have you maintained  household belongings in Alaska continuously since December 31, 2008? Yes No B (attach explanation). Do you Own Lease or Rent Live with parents Store Other C. Physical address of home or storage: ____ _______ ____________________________________________________________________________ ________ ______________________________________ _________________ _________________      CITY: STATE:  ZIP CODE:         7. At any time since DECEMBER 31, 2008 have you: A. your principal home outside of Alaska? MaintainedA.Yes No  Did you: Own Lease or Rent ive with parents ther (attach explanation) Address City, State, Zip CodeState B.country in your employment records, including leave and Claimed residency in another state or B.Yes No earnings statements if you are a member of the U.S. Armed Forces?Vehicle Plate # C. While living in Alaska, registered a vehicle as the owner or co-owner and claimed a non-resident AlaskaC.Yes No motor vehicle tax exemption?State D. full-time permanent employment in another state or country? AcceptedD.Yes No State E.you will be required to fi le a 2009 resident or part-year resident income, personal property, or Filed or E.Yes No excise tax return in another state or country? If YES, attach a copy of the return.State County F. a homestead property tax exemption in another state or country? Claimed YES, attach an explanation IfF.Yes No and copy of the homestead exemption law.State Date G. Applied If YES, attach a copy of for or received a student loan from another state or country?G.Yes No the application.  If you received a federal Stafford, Sallie Mae, Nellie Mae or Bank loan, answer NO.State Date H. in a court proceeding or affi davit that you are a resident of another state or country? DisclosedH.Yes No If YES, attach a copy of the affi davit or documents.State Date I. YES, attach a copy If Executed a will which described residency in another state or country?I.Yes No of the will.State Date L. Moved from Alaska and claimed or will claim moving expenses as a deduction on your 2009 federalL.Yes No income tax return? If YES, attach a copy of the return.State Date M. to vote in another state or country? RegisteredM. StateYes No Date N. Voted in a local or state election in another state or country?N.Yes No State Date O. a resident hunting, fi shing or trapping license in another state or country? Purchased YES, IfO.Yes No attach a copy of that state’s or country’s license regulations.State Date P.  Filedfor divorce, dissolution or legal separation in another state or country? If YES, attachP.Yes No a copy of documents.State Date Q.or maintaining a claim of residency in another state or benefits as a result of establishing  ObtainedQ.Yes No country? If YES, attach an explanation. Plate #State Vehicle R. Maintained a vehicle registered in another state or country or obtained or renewed anotherR.Yes No state's or country's vehicle registration?State License # S. a driver’s license in  Maintainedanother state or country or obtained or renewed another state’s orS.Yes No country’s driver’s license?
08155
Conned lait www.pfd.alaska.gov PO Box 110462, Juneau, AK 99811-0462