___________________
(Today’s date)
Bureau of Indian Affairs
_______________ Realty Office
(BIA Agency name)
_________________________
(Address)
_________________________
(City, State, Zip)
To Whom It May Concern:
I am preparing a will and need a current copy of my Individual Indian Money (IIM) account assets.
Please provide me a list of any interests I have in my IIM account. The following is my information:
_____________________________________________________
(My name)
_____________________________________________________
(My Tribal enrollment number)
_____________________________________________________
(My Social Security Number)
_____________________________________________________
(My mailing address)
_____________________________________________________
(City, State, and ZIP Code)
_____________________________________________________
(My telephone number)
PLEASE NOTE that some BIA Realty Offices will require that you notarize this form or send a copy of a photo ID which
clearly shows your photo, name and address.
You have my authorization to send the information to the following person who is assisting me:
_____________________________________________________
(My name)
c/o __________________________________________________
(My attorney or assistant's name)
_____________________________________________________
_____________________________________________________
(City, Sate, ZIP)
I make this request pursuant to 5 U.S.C. § 552(a) and 25 U.S.C. § 2216(e). I look forward to your
response within the required time. Thank you for your assistance with this matter.
Sincerely,
________________________________
(My signature)
PLEASE NOTE that some BIA Realty Offices will require that you notarize this form or send a copy of a photo ID which
clearly shows your photo, name and address.