Form OST 01-004/6 OST 01-004/6 Individual Indian Monies (IIM)

O MB Control No. 1035-0004 Expiration Date: Form OST 01-004/6

Individual Indian Monies (IIM) Instructions For Account Set Up, Disbursement Of Funds and Change of Address Office of the Special Trustee for American Indians If you have any questions call OST at: 1 – 888 – OST – OTFM (1–888–678–6836) TOLL FREE NUMBER
1	IIM Account Number (If Known)
2	NAME OF ACCOUNT HOLDER	First Full Middle Name Last Suffix (e.g. Jr.)
	OTHER NAMES USED (Maiden or Also Known As, etc.)	First Full Middle Name Last Suffix (e.g. Jr.)
3	DATE OF BIRTH (MM/DD/YY) And SOCIAL SECURITY #	(D.O.B.) ___ ___/ ___ ___ / ___ ___		(S.S. #) ___ ___ ___ – ___ ___ – ___ ___ ___ ___
4	CONTACT TELEPHONE NUMBER	( ) ______________________ ( ) ______________________ Area Code Number Area Code Number
5A	PAYMENT REQUEST (Before you complete this section, please read the instructions on the back of this form.)	I request all of my IIM funds be paid automatically when the account balance reaches the minimum threshold amount. Skip 5B and go to Section 6. OR I request a voluntary hold on my IIM account funds until I notify OST in writing to release this hold.
5B	VOLUNTARY HOLD PAYMENT TYPE (Before you complete this section, please read the instructions on the back of this form.) THIRD PARTY PAYMENT (Complete only if you want your payment made payable to someone other than you.)	If a voluntary hold is requested in 5A above, and you want payments made to you or a third party on specific dates, please complete the following: One-time Disbursement - I request the following amount be paid: Date ____________________ Amount _____________________ Schedule payments of my IIM account funds as follows:
		Frequency	Date(s) Use actual dates, not “until loan is paid off”		Amount (Use exact dollar amounts)
		Monthly, OR, Quarterly, OR, Other (weekly, biweekly, etc.)
		Payable To: Name: _____________________________ Address:______________________________ ___________________________________ ______________________________________ __________________________________
6	METHOD OF PAYMENT (Before you complete this section, please read the instructions on the back of this form, method of payment includes both payments for voluntary holds and third party payments.)	Direct Deposit per previously provided instructions. New or Updated Direct Deposit information. (Attach a voided check or deposit slip. If neither is available, have your financial institution complete the following information.) Routing #: __________________________ Account #: _______________________________ Name on the Account: _________________________________ Checking Savings Financial Institution Name: ______________________________________________________ Contact Telephone Number(s): ___________________________________________________ Financial Institution Address: ____________________________________________________ By Check (NOTE: OTFM will send the check to the account address of record unless third party payment is completed above.)

ACCOUNT NUMBER:__________________________________________
7	STATEMENT ADDRESS CHANGE (The address where your STATEMENT will be mailed.)
	FROM (Old Address)				TO (New Address)
	Street Address, PO Box, Rural Route Box ________________________________________________ Apt. No., Building Name ________________________________________________ City State Zip Code				ADDRESS:____________________________________________________ Street Address, PO Box, Rural Route Box _____________________________________________________________ Apt. No., Building Name _____________________________________________________________ ADDRESS:_______________________________________ City State Zip Code
8	CHECK ADDRESS CHANGE (The address where your CHECK will be mailed. Complete only if the address is different from your statement address.)
	Mark this box if the check(s) are to be mailed to same address as statements in Section 3 above.				ADDRESS: _____________________________________________________________ Street Address, PO Box, Rural Route Box _____________________________________________________________ Apt. No., Building Name __________________________ ____________________ ____________ City State Zip Code
9		YOUR SIGNATURE OR THUMBPRINT Your signature or thumbprint must be witnessed. The witness must complete Section 9 on the back of this form.	I certify that the information provided is true and correct.
10		TODAY’S DATE (MM/DD/YY)
This section must be completed for all requests. You must have a witness of your signature or thumbprint and the witness must complete Section 9. The witness must be age 18 or older.
11		Witness of Account Holder’s Signature or Thumbprint I, the undersigned, certify that this request was signed in my presence. ________________________ Witness Signature		__________________________________________ ________________ Printed Name of Witness Date Address:____________________________________(_____)____________ Street Address, Apt. No., PO Box, Rural Route Telephone Number ____________________________________________________________________ City State Zip Code
	COMPLETE FOR TELEPHONE REQUESTS
	I. Telephone request received: Date: ______________________ Time: _____________ **Use security questions in Part II, to verify the account holder’s identity.					II. Security Question(s): When changes are requested by telephone, verify the identity by using a combination of any 2 of the following: Social Security Number (last 4 digits or whole) Date of Birth Address of Record I IM Account # Approximate date and amount of the last check received Mother’s Maiden Name (if available in TFAS) NOTE: If identity is not verified, refer account holder to OST Field Office to make changes in person or by mail.
	III. OST Employee Information: Print Name: ________________________________________ Position Title: _______________________________________ Office Phone Number: ________________________________ Signature: ___________________________________________

Name of Account Holder:
Account Number:
	COMPLETE FOR REQUESTS RECEIVED BY MAIL OR IN PERSON
	Date Received:Position Title
	Print OST Employee Name:			Signature:
DO NOT WRITE BELOW THIS LINE (FOR OST USE ONLY)
		Account Set up Disbursement Request Change of Address Restricted Unrestricted
		Disbursement Authorizing Official Acct Bal.____________________	Date:		Date:
			Signature:		Signature:
			Print Name:		Print Name:
	CSS#________________________ DATE________________			SERVICE CENTER #___________________________
	Date:___________ Prepared By_______________			RFM AUDIT TRAIL
	Approved By____________________ Post QA_________________			____________ ______________ _______________ INITALS TRAN # DATE
	Initiator/CSS Encoder____________________________________			Pre Q&A/CSS Approval:________________________________
	TFAS Verification:________________________________

INSTRUCTIONS FOR COMPLETING SECTIONS 5 AND 6

Section 5A Check () only one box:

1. If you check the first box, an automatic payment will be made whenever the account balance reaches the minimum threshold.

2. If you check the second box, a voluntary hold will be placed on your account. This hold will remain on your account until you notify us in writing to release the hold. Disbursements from your account will only be made in accordance with written authorization received from you.

Section 5B If you requested a voluntary hold by checking the second box in 5A, the funds may be released in the following manner:

1. If you check the One-time Disbursement box, a payment will be made to you or a third party for the amount and date specified. If you want the payment to be made to a third party you must complete the Third Party Section.

2. If you check the Schedule Payments box, you may have the funds disbursed to you or a third party according to a scheduled payment plan. If you want the payment to be made to a third party you must complete the Third Party Section. Payments may be monthly, OR quarterly OR according to another timeframe specified by you. You must indicate the exact date(s) and exact dollar amount(s) to be made, e.g., pay to First National Bank $200 on the 15^th of each month. Instructions such as “until loan is paid off” are NOT acceptable and payments will not be processed. If sufficient funds are in the account the day that a scheduled payment is to be made the payment will be made. If sufficient funds are NOT in the account and therefore unavailable, the account will not be overdrawn and a notice of non-payment will be mailed to the account holder’s address of record (statement address).

3. If you complete the third party payment section (name and address), this means the disbursement will be made payable to someone other than you, i.e., the third party.

Section 6 Check () only one box.

1. If you are requesting a check, mail time from Albuquerque, New Mexico varies dependent on the destination. The use of the DIRECT DEPOSIT function will place the funds directly into your checking or savings account on the same day a check would be mailed. In addition to faster availability of funds, direct deposit safeguards against lost, stolen or forged checks.

2. If you check New or Update Direct Deposit Information, this indicates that your funds will be deposited directly into a checking or savings account at the financial institution of your choice. Check this box if you are changing the financial institution or the account number has changed.

3. If you want a direct deposit and do not have the deposit slip or voided check, you must obtain the necessary information from your financial institution. For third party direct deposit, you must have that person/party provide the necessary information.

Paperwork Reduction Act Statement: This information is collected to manage trust fund accounts for account holders. The information is supplied by a respondent to obtain or retain a benefit, which is ownership of an Individual Indian Monies (IIM) account. It is estimated that responding to the request will take an average of one-fourth hour (15 minutes) to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the form, please send them to the Office of the Special Trustee for American Indians, ATTN: OTP, Information Collection Clearance Officer, 4400 Masthead NE, Albuquerque, NM 87109. Note: Comments, as well as the names and addresses of individuals, who submit comments, are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget (OMB). The collection has been assigned a control number and expiration date by OMB. The number is located at the top left corner of the form and the expiration date follows immediately after the control number. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB control number.

Privacy Act Statement: This information collection document contains information that is covered under the Privacy Act of 1974, as amended, in the following system of records: “Individual Indian Money (IIM) Trust Funds—Interior, OS—02.” The Office of the Special Trustee for American Indians will not disclose any record containing such information without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary use of this information is to manage the collection, investment, distribution, and disbursement of individual and tribal income from Indian land trust funds.

Examples of others who may request this information are: (1)Individual Indian trust account holders or their heirs (2) contractors who service and maintain the system for the Department ensuring that all provisions of the Privacy Act, the Trade Secrets Act, the Indian Minerals Development Act and all other applicable laws, regulations, and policies relating to contracting and record security are met (3) U.S. Department of Justice, a court, adjudicative or other administrative body or to a party in litigation before a court, adjudicative or other administrative body (4) the appropriate federal, state, tribal, or local or foreign governmental agency responsible for investigating, prosecuting, enforcing or implementing a statute, rule, regulation, order or license in the event this agency becomes aware of a violation or potential violation of a statute, rule, regulation, order or license or (5) a congressional office in response to an inquiry by that office by the individual to whom the record pertains. Collection of your Social Security Number is authorized by 31 USC 7701.