08155 Audit Form 2010

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: ...