02-1896c (Rev. 4/20) G:\Communications_Only\200 Products\206\General\02-1896c.indd
FOR OFFICE USE ONLY
Toll-Free: (800) 821-2251
alaska.gov/drb
Division of Retirement and Benets
P.O. Box 110203
Juneau, AK 99811-0203
Juneau: (907) 465-4460
TDD: (907) 465-2805
Fax: (907) 465-3086
Retirement
and
ALASKA DIVISION OF
Application for Alaska Cost-of-Living
Allowance COVID-19 Waiver
I,_______________________________ wish to apply for a waiver per statute AS 39.35.522, of any Alaska Cost-of-I,_______________________________ wish to apply for a waiver per statute AS 39.35.522, of any Alaska Cost-of-
Living Allowance overpayment that I may owe due to my inability to return to Alaska within 90 days of departure as a Living Allowance overpayment that I may owe due to my inability to return to Alaska within 90 days of departure as a
result of the COVID-19 travel restrictions and result of the COVID-19 travel restrictions and understand that I must submit my request for waiver within 30 days understand that I must submit my request for waiver within 30 days
of my return to Alaska.of my return to Alaska.
Date of Departure: _________________
Intended Date of Return: _________________
Actual Date of Return: _________________
I understand, for the purposes of AS 39.35.480 (PERS) or AS 14.25.142 (TRS), to be entitled to receive COLA, I must I understand, for the purposes of AS 39.35.480 (PERS) or AS 14.25.142 (TRS), to be entitled to receive COLA, I must
be domiciled and physically present in the State of Alaska. However, due to circumstances related to COVID-19, I was be domiciled and physically present in the State of Alaska. However, due to circumstances related to COVID-19, I was
unable to return when I initially intended. I am providing, along with this waiver, documentation showing:unable to return when I initially intended. I am providing, along with this waiver, documentation showing:
1. 1. that I had intended to return to Alaska within 90 days, andthat I had intended to return to Alaska within 90 days, and
2. 2. why I was unable to do so.why I was unable to do so.
Please provide as much documentation as possible to establish your intent.Please provide as much documentation as possible to establish your intent.
ALL FIELDS BELOW ARE REQUIRED.
NAME (LAST, MAIDEN, FIRST, MI) HOME TELEPHONE NUMBER
PHYSICAL ADDRESS
CITY STATE ZIP+4
MAILING ADDRESS
CITY STATE ZIP+4
I have completed the Alaska Cost-of-Living Allowance Return to Alaska Notification form and understand this form must be
mailed from within the State of Alaska, pursuant to 2 AAC 35.240(a). Private meter postmarks will not be accepted.
Upon receipt of this waiver, the Division will compute the amount of your overpayment for the time you were absent from Alaska and
submit your request for waiver to the Commissioner of Administration for review. You will be notied once the review is complete.
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 falsied. Upon conviction, the misdemeanor is punishable by a ne, by imprisonment, or
both and may lead to forfeiture of all rights to benets from the system.
SIGNATURE SOCIAL SECURITY NUMBER OR RIN DATE
