Child's First Name as last reported to PFD
MI
Child's Last Name as last reported to PFD
Child's Social Security Number
Child's Date of Birth
Your Daytime Telephone Number
Your Message Telephone Number
Change my Child's First Name to
Change my Child's Middle Initial to
Change my Child's Last Name to
Alaska Department of Revenue
Permanent Fund Dividend Division
Use this form to report a change in your child's name or add or correct your child's SSN with the Permanent Fund Dividend
(PFD) Division. The PFD Division will apply the change or addition to current year records and any other prior year records
that are still active. Attach a letter if you want this change applied differently.
Child Information
Change/Addition Form
PFD Division Use Only
PFD ALN: 20090
04416
04416 (Rev. 12/08)
www.pfd.alaska.gov
Add my Child's SSN as follows
Correct my Child's SSN to
Signature
Date
Printed name of the person who signed
Social Security Number
The person who signed the child's application must complete the following portion.
Other Parent Signature (if filing together)
Date
Other Parent Printed Name
Other Parent Social Security Number
Send or deliver this completed form to:
I certify that I am authorized to make the changes listed above. If I did not sponsor the child listed above, I must attach a Power of
Attorney.
04416
SIGNATURE IS
REQUIRED
Alaska Department of Revenue
Permanent Fund Dividend Division
11th Floor, State Office Building
PO Box 110462
Juneau, AK 99811-0462
Phone (907) 465-2326
Fax (907) 465-3470