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

OMB Control No. 1035-0004

Expiration Date: MM/DD/2013

Form OST 01-004

Individual Indian Monies (IIM)
Instructions for Disbursement of Funds and Change of Address
Office of the Special Trustee for American Indians -- http://www.doi.gov/ost/
If you have any questions call OST at: 1 – 888 – OST – OTFM (1–888–678–6836) TOLL FREE NUMBER

1
2

IIM ACCOUNT NUMBER OR
TRIBAL ID NUMBER (If Known)
CURRENT LEGAL NAME OF
ACCOUNT HOLDER

First

Full Middle Name

Last

Suffix (e.g. Jr.)

First

Full Middle Name

Last

Suffix (e.g. Jr.)

OTHER NAMES USED
(Maiden or Also Known As, etc.)

3

DATE OF BIRTH (MM/DD/YYYY)
and SOCIAL SECURITY #

4

CONTACT TELEPHONE
NUMBERS and EMAIL
ADDRESS

___ ___/ ___ ___ / ___ ___ ___ ___
Date of Birth

(

___________ -- __________-- _______________
Social Security Number

) _________________________

Area Code

Telephone Number

(

) _________________________

Area Code

Cell Phone Number

Email address ___________________________________________________________

Select one of the following options:
Automatically disburse all of my funds: I request all of my IIM funds be paid automatically
when the account balance reaches the minimum threshold amount.

OR
Specific instructions to disburse my funds: I request that my IIM funds be disbursed as
follows (check only one box):
No Current Disbursements - I request that my IIM funds be held in my account until I
provide further instructions.
One-Time Disbursement - I request that $__________________ be paid to me on

,

______________ and the balance be held in my IIM account until I provide
(Date)

5

further instructions.

PAYMENT INSTRUCTIONS
Scheduled Disbursements of Account Balance – I request that 100% of the account
balance of my IIM funds be paid to me (circle one of the following: monthly, quarterly or
annually) starting on _________________.
(Date)
Other - I request that my IIM funds be disbursed as follows:

_______ ____
___________________

Third Party Payment
Complete the following only if you want your payment made payable to someone other than you.
Printed Name of Third Party Payee: _________________________________________
Address of Third Party Payee:
_____________________________________________________________________________
Street Address, PO Box, Rural Route Box
_____________________________________________________________________________
Apt. No., Building Name
________________________________ ________________________ __________________
City
State
Zip Code

(

) _________________________

Area Code

Telephone Number

OMB Control No. 1035-0004

Expiration Date: MM/DD/2013

Form OST 01-004

Individual Indian Monies (IIM)
Instructions for Disbursement of Funds and Change of Address
Office of the Special Trustee for American Indians -- http://www.doi.gov/ost/
If you have any questions call OST at: 1 – 888 – OST – OTFM (1–888–678–6836) TOLL FREE NUMBER

6

METHOD OF PAYMENT
Must select one option.
NOTE: The electronic transfer of your
IIM funds to an OST Debit Card or
Direct Deposit to your checking or
savings account helps to safeguard
against lost, stolen or forged checks.
In addition, you will generally receive
your IIM funds quicker with electronic
transfer since mail time for a check will
vary depending on the United States
Postal Service and the destination.

Direct Deposit to checking or savings account
Banking information – Attach a voided check or provide the following information:
Routing #: __________________________ Account #: _______________________________
Name on the Account: _________________________________________________________
Financial Institution Name: ______________________________________________________
Contact Telephone Number(s): ___________________________________________________
Financial Institution Address: ____________________________________________________

OR
OST Debit Card

OR
Check
NOTE: If you want your check to be delivered to an address different than the mailing address set
forth in Section 7 below, please provide your check mailing address on a separate paper.

7

MAILING ADDRESS
NOTE: Complete this section even
if you are requesting an OST Debit
Card or if you are receiving your
funds by Direct Deposit.

_____________________________________________________________________________
Street Address, PO Box, Rural Route Box
_____________________________________________________________________________
Apt. No., Building Name
______________________________ ____________________ ________________________
City
State
Zip Code
Please check if this is a new address

8

YOUR SIGNATURE
OR MARK

I certify that the information provided is true and correct.

NOTE: Your signature or mark
must be witnessed. The witness
must complete Section 9.

_________________________________________
Account Holder Signature or Mark

________________
Date

I, the undersigned, certify that this request was signed in my presence.

9

WITNESS OF ACCOUNT
HOLDER’S SIGNATURE OR
MARK

NOTE: The witness must be age 18 or
older, and must sign immediately after
the Account Holder signs the
document in Section 8. The dates in
Section 8 and Section 9 must be
identical.

_________________________________________
Witness Signature

________________
Date

__________________________________________________________________
Printed Name of Witness
Address:____________________________________
Street Address, Apt. No., PO Box, Rural Route

(_____)_______________
Telephone Number

______________________________ ____________________ ______________________
City
State
Zip Code

THIS SECTION FOR OST USE ONLY
ACCOUNT NUMBER:

SERVICE CENTER NUMBER:

DISB TICKLER/BCS NUMBER:

CSS NUMBER:

OMB Control No. 1035-0004

Expiration Date: MM/DD/2013

Form OST 01-004

Individual Indian Monies (IIM)
Instructions for Disbursement of Funds and Change of Address
Office of the Special Trustee for American Indians -- http://www.doi.gov/ost/
If you have any questions call OST at: 1 – 888 – OST – OTFM (1–888–678–6836) TOLL FREE NUMBER

THIS SECTION FOR OST USE ONLY
COMPLETE FOR TELEPHONE REQUESTS
I. Telephone request received:
Date: _______________________ Time: _______________
**Use security questions in Part II, to verify the account holder’s
identity.
III. OST Employee Information:
Print Name: _________________________________________

II. Security Question(s): When changes are requested by
telephone, verify the identity by using a combination of any 2 of the
following if information is available in TFAS:
Social Security Number (last 4 digits or whole)
Date of Birth
Last Address of Record
IIM Account Number
Approximate Date and Amount of the Last Disbursement

Position Title: ________________________________________
Office Phone Number: _________________________________

NOTE: If identity is not verified, refer account holder to OST Field
Office to make changes in person or by mail.

Signature: __________________________________________
Security password verified?

Yes

Account holder has not created a security password

COMPLETE FOR REQUESTS RECEIVED BY MAIL OR IN PERSON
Date Received:

Position Title:

Print OST Employee Name:

Signature:
Date:

Disbursement Authorizing Official
Acct Bal.____________________

Signature:
Print Name:

CSS#_______________________ DATE____________________

SERVICE CENTER #____________________________

Date:_______________________ Prepared By_______________

RFM AUDIT TRAIL

Approved By_________________ Post QA__________________

______________
INITIALS

CSS Encoder__________________________________________

Pre Q&A/CSS Approval________________________________

TFAS Verification_______________________________________

________________
TRAN #

________________
DATE

OMB Control No. 1035-0004

Expiration Date: MM/DD/2013

Form OST 01-004

Individual Indian Monies (IIM)
Instructions for Disbursement of Funds and Change of Address
Office of the Special Trustee for American Indians -- http://www.doi.gov/ost/
If you have any questions call OST at: 1 – 888 – OST – OTFM (1–888–678–6836) TOLL FREE NUMBER
Paperwork Reduction Act Statement: Paperwork Reduction Act Statement: This information is collected to manage trust fund accounts for
account holders. The information is supplied to obtain or retain a benefit, which is ownership of an Individual Indian Monies (IIM) account, by authority of
the American Indian Trust Fund Management Act of 1994. It is estimated that responding to the request will take approximately 15 minutes to complete,
including the time it takes to gather the information and fill out the form. Your information will be held confidential by the Department, except as
described below in the Privacy Act Statement. If you wish to provide comments about the Form, including the accuracy of the burden estimate and any
suggestions for reducing the burden, please send them to the Office of the Special Trustee for American Indians, ATTN: Office of Trust Regulations,
Policies and Procedures, 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 a valid OMB control number appears on the face of the form.
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: OS—02, ―Individual Indian Monies (IIM) Trust Funds.‖ 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. Submission of the information is required to
obtain the benefit of having an Individual Indian Money account. The Office of the Special Trustee for American Indians will not disclose any record
containing such information without the written consent of the respondent except for the following: (1) it is needed to be sent to appropriate agencies,
courts or parties for legal actions, (2) to the Dept. of Treasury so that it can make disbursements, (3) to the IRS for legally required reporting, (4) to
appropriate agencies or law enforcement bodies concerning a specific potential violation of a statute or regulation, (4) to agencies or appropriate parties
in the event of a breach for remediation purposes, (5) or to a party such as Congress to answer inquiries filed by the account holder. Other examples of
those who may request this information are: (6) Individual Indian trust account holders, their heirs, guardians, or agents (7) Contractors, but only after
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 security are met, who:
(a) provide trust and other services to beneficiaries;
(b) provide, use, operate or facilitate various components of the system;
(c) service and maintain the system for the Department.
Collection of your Social Security Number is authorized by 31 USC 7701.