Alaska Form Gen020 – Fill Out and Use This PDF

Alaska Cost-of-Living Allowance (COLA)

Afidavit of Residency		ＩＲＵ＃ＲＩＩＬＦＨ＃ＸＶＨ＃ＲＱＯ＼＃

	Division of Retirement and Beneits	Juneau: 465-4460
Toll-Free: 1-800-821-2251	PO Box 110203	TDD: (907) 465-2805
alaska.gov/drb	Juneau, Alaska 99811-0203	Fax: (907) 465-3086

Physical Address (Street Address, City, State)

Mailing Address (City, State, ZIP+4)

COLA is for retirees who reside in the State of Alaska. Resides means domiciled and physically present in the state.

2 AAC 36.210 (TRS) and 2 AAC 35.240 (PERS) states a person domiciled in the state is a person who:

(1)maintains his or her principal place of residence in the State of Alaska;

(2)demonstrates at all times during an absence an intent to return to Alaska and remain a resident of Alaska;

(3)does not claim residency outside the state or obtain beneits or residency in another state or nation.

The administrator’s determination of an applicant’s residency will be based on the totality of relevant circumstances. Intent is demon- strated by establishing and maintaining customary ties indicative of Alaska residency.

AS 39.35.670 (PERS) and AS 14.25.210 (TRS) — A person who knowingly makes a false statement, or falsiies or permits to be falsiied a record of this system, in a attempt to defraud the system, is guilty of a Class A Misdemeanor and upon conviction is punishable by a ine of not more than $500 or by imprisonment for not more than 12 months, or by both.

This form must be certiied by an adult Alaska resident not related to the applicant who can verify the applicant’s Alaska residency.

CERTIFICATION: I certify the above applicant is a resident of Alaska and intends to remain a resident of Alaska. I further certify the applicant resides in the above physical address which is his/her true, ixed permanent home and principal residence. I have irst hand knowledge the applicant’s household goods are maintained in this residence and it is inhabited primarily by the applicant.

Mailing Address

Signature of certiier, witnessed by one of the following: DRB Representative or Division of Personnel Staff

Signature

__________________________________ Title ____________________________ Date

/

/______

OR, SIGNATURE WITNESSED BY A NOTARY

On this

day of

20 ,

personally appeared before me whose identity

I proved on the basis of satisfactory evidence to be the signer of the participant's signature above, and he/she acknowledged that he/she executed it.

		Notary Public ____________________________________________________________
	NOTARY SEAL OR	State of _________________________	and Borough/County of __________________
	POSTMASTER
	STAMP	Residing at ______________________	Commission Expires ____________________
	REQURIED

GEN020 (Rev. 3/11)

g:/publications/forms/general/gen020.indd