Form 04-083 - Change Of Information Template
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1CHANGE OF INFORMATION
Use this form to change your name or address or to add a Social Security number (SSN) if you have already filed a dividend
application but have not yet received a dividend check. NOTE: To help ensure that the dividend file will be changed before the payments
are made, file this form by September 15. Use a separate form for each household.
PLEASE PRINT CLEARLY
Enter the DIVIDEND YEAR(S) for which these changes apply so the
1.
department will be sure to correct each file.
DIVIDEND YEAR(S)
2.
CORRECT ADDRESS REQUIRED. In Box A below, enter your old or incorrect address. In Box B below, enter the new or correct
address for your household. Even if your address has not changed, complete Box B, it will help the division identify the right record.
A. OLD OR INCORRECT ADDRESS
B. NEW OR CORRECT ADDRESS
3.
Complete all the information below for each person whose name or address should be changed, or who has a SSN to add or correct.
Include all persons who have a change and who filed their applications together as a household. Use additional pages as necessary.
CHECK ACTION NEEDED
SSN
DATE OF BIRTH
CORRECT NAME (First, M.I., Last)
Change
Change
Change
Address
Name
SSN
Month
Day
Year
1.
2.
3.
4.
5.
4.
NAME CHANGE ONLY. If a name is being changed or corrected, enter the line number of the person from above and the name as
stated on the application or as it appeared on the dividend receipt. Attach marriage certificate or legal documents showing name
change.
5.
I certify that I am authorized to make this change. (Attach a copy of a completed Power of Attorney for
each person listed above who is NOT a member of your family)
YOUR
SIGNATURE IS
YOUR SIGNATURE
SSN
Date of Birth
Month
Day
Year
REQUIRED
Daytime Telephone Number
Date
Printed Name of Person Who Signed
Web Site:
Deliver the completed form to any dividend information office, or send to:
Dividend Address Change
Permanent Fund Dividend Division
1016 West Sixth Avenue, Suite 100
Anchorage, AK 99501
Form 04-083 (Rev. 10/97)
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