Form OST--01-004 Individual Indian Monies (IIM) Instructions for Disburse

Trust Funds for Tribes and Individual Indians, 25 CFR 115

OST IIM Form 1035-0004

Trust Funds for Tribes and Individual Indians, 25 CFR Part 115 [Individual Indians - Form]

OMB: 1035-0004

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OMB Control No. 1035-0004 Expiration Date: MM/DD/2016 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 (18886786836) TOLL FREE NUMBER

Shape8

1

IIM Account Number OR TRIBAL ID NUMBER (If Known)


2

CURRENT LEGAL 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/YYYY)

and SOCIAL SECURITY #

________________________________

Date of Birth

___________ -- __________-- _______________

Social Security Number

4

CONTACT TELEPHONE NUMBERS and EMAIL ADDRESS

( ) _________________________ ( ) _________________________

Area Code Telephone Number Area Code Cell Phone Number


Email address __________________________________________________________________

5

PAYMENT INSTRUCTIONS


Select one of the following options:

Shape2

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

Shape3

Specific instructions to disburse my funds: I request that my IIM funds be disbursed as follows (check only one box):

Shape4

No Current Disbursements - I request that my IIM funds be held in my account until I provide further instructions.

Shape5

One-Time Disbursement - I request that $__________________ be paid to me on ______________, and the balance be held in my IIM account until I provide

(Date) further instructions.

Shape6

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)

Shape7

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



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.

Shape9 Shape1 Direct Deposit to Checking Account Direct Deposit to 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): ___________________________________________________

Shape10 OR OST Debit Card


If Direct Deposit or OST Debit Card is selected, indicate

the preferred method of ACH Deposit Notification:


Shape11 Regular Mail

Shape12 Email

Shape13 Text

Shape14 No Notification


Shape15

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

Shape16 Please check if this is a new address.


8

YOUR SIGNATURE

OR MARK

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

I certify that the information provided is true and correct.




_______________________________________ ________________

Account Holder Signature or Mark Date


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.

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

_________________________________________ ________________

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:



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.

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:

Shape17 Social Security Number (last 4 digits or whole)

Shape18 Date of Birth

Shape19 Last Address of Record

Shape20

IIM Account Number

Shape21 Approximate Date and Amount of the Last Disbursement



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:


Signature: _________________________________________


Print Name: ________________________________________


Position Title: _______________________________________


Office Phone Number:_________________________________



Shape23 Shape22 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:



Disbursement Authorizing Official


Acct Bal.____________________

Date:

Signature:

Print Name:



CSS#_______________________ DATE____________________

SERVICE CENTER #____________________________


Date:_______________________ Prepared By_______________

RFM AUDIT TRAIL


Approved By_________________ Post QA__________________

______________ ________________ ________________

INITIALS TRAN # DATE


CSS Encoder__________________________________________

Pre Q&A/CSS Approval________________________________


TFAS Verification_______________________________________

Account #___________________________________________


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 Reform 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.


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