The Alaska Gen020 form, also known as the Cost-of-Living Allowance (COLA) Affidavit of Residency, is a crucial document for retirees living in Alaska. This form serves to confirm that an individual is a resident of the state, demonstrating their intent to maintain residency and not claim residency elsewhere. For those who qualify, completing this form is an essential step in accessing benefits available to Alaska residents.
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The Alaska Gen020 form, officially known as the Cost-of-Living Allowance (COLA) Affidavit of Residency, plays a crucial role for retirees living in Alaska. Designed to confirm residency, this form ensures that individuals receiving COLA benefits are indeed residing in the state. A key aspect of the form is its requirement for applicants to demonstrate their intent to maintain Alaska as their principal place of residence. This involves showing that they are physically present in the state and have established customary ties indicative of residency. The regulations stipulate that applicants must not claim residency in another state or country, further solidifying their commitment to living in Alaska. To validate the information provided, the form must be certified by an unrelated adult resident of Alaska who can attest to the applicant's residency status. This certification process is vital, as it helps maintain the integrity of the benefits system. Furthermore, the form outlines the serious consequences for anyone who knowingly provides false information, including potential misdemeanor charges. Understanding the nuances of the Gen020 form is essential for retirees to ensure compliance and secure their benefits effectively.
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
Name (First, M.I., Maiden, Last)
Social Security Number (last 4 digits)
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.
Print name of person certifying this form
Telephone Number
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
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