OMB Control No. 1035-0004 Expiration Date: 01/31/2020 Form OST 01-004
Individual Indian Money (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
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.
When oil & gas royalties are posted to
your IIM account we will mail an
Explanation of Payment (EOP) to you.
If your royalty payment is sent to you,
either by Direct Deposit or by check,
the EOP will be mailed to you at the
If your royalty payment is held in your
IIM account, an EOP will be mailed to
you the day after it posts to your IIM
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): ________________________________
OR OST Debit Card
If Direct Deposit or OST Debit Card is selected, indicate
the preferred method of ACH Deposit Notification:
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.
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.
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
WITNESS OF ACCOUNT
HOLDER’S SIGNATURE OR
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
I, the undersigned, certify that this request was signed in my presence.
Witness Signature Da
Printed Name of Witness
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: