Adult Internet Filing Signature Form - 2001 - Alaska Department Of Revenue
ADVERTISEMENT
1Alaska Department of Revenue
Permanent Fund Dividend Division
2001 Adult Internet Filing Signature Form
Print, sign and mail this form to:
Alaska Department of Revenue
Permanent Fund Dividend Division
PO Box 110462
Juneau, AK 99811-0462
Complete the following:
Social Security Number
Date of Birth (MM/DD/YY)
Confirmation Number (If known)
UWI
First Name
M.I.
Last Name
Zip Code
Mailing Address
City
State
Daytime Telephone Number
Email Address
Read the following statements carefully and sign below. Don’t change anything.
I certify that:
- I am now and intend to remain an Alaska resident indefinitely.
- I was an Alaska resident for all of 2000.
- I haven’t claimed residency in another state.
- I was in the state of Alaska for at least 72 consecutive hours in 1999 or 2000.
I understand that if what I say is not true, it is a criminal offense and if I am convicted,
in addition to any criminal penalties:
- I will lose this dividend and all future dividends.
- I must pay back all dividends that I have been paid.
I understand that if I deliberately misrepresent or recklessly disregard a fact, I am liable
for civil penalties:
- I will lose this dividend and my next five dividends.
- I may have to pay a fine of up to $5,000.
I authorize the Alaska Department of Revenue to obtain information to verify my
eligibility. I also authorize the Social Security Administration to release any information
regarding my identity to the Department of Revenue. I agree that a copy of this authorization
I certify that the information I submitted electronically is true and correct.
Your Signature
Date
Filing Deadline: April 2, 2001
See Page 2 for Additional Information
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial