Alaska Department of Revenue

04416
PFD Division Use Only
Permanent Fund Dividend Division PFD ALN:

Child Information
Change/Addition Form

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'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 Daytime Phone Number Message Phone Number

Change my Child's First Name to

Change my Child's Middle Initial to

Change my Child's Last Name to

Add my Child's SSN as follows

Correct my Child's SSN to

Correct my Child's date of birth 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.

Signature of Sponsor Date

SIGNATURE IS
REQUIRED Printed name of the person who signed Social Security Number

Send this completed form to:

Permanent Fund Dividend Division
PO Box 110462
Juneau, AK 99811-0462

Phone (907) 465-2326

Fax (907) 465-3470
Confidential 04416
14416 (Rev. 06/10) www.pfd.alaska.gov