02-1896a (Rev. 10/12) g:/publications/forms/general/02-1896a.indd
I returned to Alaska and wish to receive Alaska Cost of Living Allowance (COLA) payments. I understand, for
the purposes of AS 39.35.480 (PERS) or AS 14.25.142 (TRS), that in order to be entitled to receive COLA, I
must be domiciled and physically present in the State of Alaska. Further, I understand that a standard legal
definition of domicile is:
“That place where a person has his or her true, fixed, and permanent home and
principal establishment, and to which whenever absent, he or she has the intention
of returning.”
I will notify the Division of Retirement and Benefits whenever I plan to leave Alaska for a continuous period
that exceeds 90 days or when I have been out of Alaska for more than 90 days. I understand that if I am gone
for 91 days or more, COLA will not be paid for the entire absence. I understand that I am required to repay
any overpayments to the Division of Retirement and Benefits for COLA received during any ineligible periods.
Name (Last, Maiden, First, MI)
Physical Address (Street, City, State, ZIP+4)
Mailing Address (Street or P.O. Box, City, State, ZIP+4)
Home Telephone Number
I am receiving benefits from: q PERS q TRS q BOTH
Signature Social Security Number or RIN Date
NOTE: Pursuant to AS 39.35.670 (PERS) and AS 14.25.210 (TRS), it is a misdemeanor to knowingly or
willfully make a false statement or permit retirement records to be falsified. Upon conviction, the
misdemeanor is punishable by a fine, by imprisonment, or both, and may lead to forfeiture of all rights
to benefits from the system.
If you are traveling back to Alaska, please mail this form upon your arrival in Alaska. Private meter postmarks
will not be accepted.
Alaska Cost-of-Living Allowance
Return to Alaska Notification
FOR OFFICE USE ONLY
Toll-Free: (800) 821-2251
alaska.gov/drb
Division of Retirement and Benefits
P.O. Box 110203
Juneau, Alaska 99811-0203
Juneau: (907) 465-4460
TDD: (907) 465-2805
