OMB Control No. 1035-0004 Expiration Date: 07/31/2013 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.goviost! Ifyou have any questions call OST at: 1 - 888 - OST - OTFM_(1-888-678-6836) TOLL FREE NUMBER lM ACCOUNT NUMBER OR 4 | TRIBAL ID NUMBER crv) CURRENT LEGAL NAME OF 2 ACCOUNT HOLDER First Full Middle Name Last Suffix (0.9. Jr OTHER NAMES USED (Maiden or Also Known As, ett.) First Full Middle Name, Lest. Suffix (e.g Jr} 3. | DATE OF BIRTH awoorry) and SOCIAL SECURITY # Date oF Bith Sse Seay NurbeF CONTACT TELEPHONE co) Co) 4 wMeeRS and EMAIL Area Code Telephone Number ‘Area Code Cell Phone Number Email address, Select one of the following options: C1 Automaticanty disburse all ot my runds: | request all ot my 1IM funds be paid automaticaly \when the account balance reaches the minimum threshold amount OR Specific instructions to disburse my funds: | request that my IM funds be disbursed as follows (check only ene box) No Curront Disbursements - | roquset that my lIM funds bo hele in my aoseunt unt! | provide turer instructors. One-Time Disbursement -| request that $ te paid io meon + ond the balance be held in my IIM account uni! provide t further instructions. 5 | PAYMENT INSTRUCTIONS [scheduled disbursements of Account Balance —|roquost that 100% ofthe aooount balance omy IN funds be paid io me (cce one ofthe following. monthly, quarterly or annually) sting on, Taiay other - request nat my i funds be cisbursed as rolows, Third Party Payment Complete the folowng only it you want your payment made payable to someone other than you. Printed Name of Third Party Paye Address of Third Party Payee: Greet Adress, PO Box, Rural Route Box Fat We, Balding Name a 1 Coy Area Code Telephone NumberOMB Control No. 1035-0004 Expiration Date: 07/31/2013 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.d jov/ost/ If you have any questions call OST at: 1 — 888 - OST - OTFM_(1-888-678-6836) TOLL FREE NUMBER 6 | METHOD OF PAYMENT T rect Deposit o checking or savings account Must select one option. Banking information - Attach a voided check or provide the following information: NOTE: the eecrone tansor of your littrae osncst beot camo | Rouge Direct Deposit fo your cnecking oF savings account Helps to safeguard against lot, stolen or forged cnecks, 'p adtion, you wil generally recsive your Il funds quicker with etectronic transfer since mail time for acheck will | OR vany depending cn the United States Postal Service end tho costnaton. | [-] ost debit card oR CO check NOTE: If you wart your check to be delvored fo an addross dfforont than the maling addrose sot fort in Seciion 7 below, please provide your check mailing address on a separate pacer, Name on tha Account: Financial Institution Nari Contact Telephone Numbers) Fanci Insttution Adcress MAILING ADDRESS 7 | MEN APRESS aR, POR, RRB Iyos are roquesing an OST Dos Gad orif you are receving your FECA Bi foray Sect Sopot - sae ip ode CO Please check if this is a new address | certify that the information provided is true and correct, 8 | YOUR SIGNATURE ‘tty that ‘tion iw rect OR MARK NOTE: Your signature or mark must be witnessed. The witness must complete Section 8 acount Folder Signals of Wark Date I the undersigned, cory that this requost was signed in my presence. g | WITNESS OF ACCOUNT HOLDER'S SIGNATURE OR MARK Witness Signature Date NOTE: The witness must be age 18 or older, and must sign immediatly ater tho Acscunt Holdor signs tho Printed Name of Winees document in Secion€, The dates in Section 8 and Section 9 must be Adcress: ) — ‘aentical ‘Sirect Adaress, Apt No, PO Box Rural Route Telephone Number Gy ———Stals ip Coae THIS SECTION FOR OST USE ONLY ACCOUNT NUMBER: SERVICE CENTER NUMBER: DISB TICKLER/BCS NUMBER: (CSS NUNBER: