DOI_BIA_v1
BIA Trust Payment
Use this form to make payments related to the purchase or use of Indian lands and/or resources.
Fields marked with an asterisk (*) must be filled in with accurate information. Failure to enter accurate
information is these required fields may result in your payment(s) not being accurately and/or timely
applied to the payment(s) you owe.
For information on how to use this form click here.
* Required Field
Payer Information
Your Name *
Telephone Number *
(First Name, Middle Initial, Last Name)
Company Name *
Email Address *
Select the BIA Agency you want to pay *
Note: all payments on this form must be for the same BIA Agency. Do not included direct
payments.
Line
Invoice Number
*
Verify Invoice
Number *
Lease Number
*
Payment
Amount *
#1
Total Payment Amount *
$0.00
Direct payments to land owners are only authorized where there is specific written
authorization contained in the terms of a BIA approved contract or contract modification. If you
are authorized to make direct payments to a land owner, you must certify that you have done
so, by checking "Yes" below. Willfully falsifying certifications or affirmations may subject you to
criminal penalties, including fines and/or imprisonment. (Title 18 USC)
Did you make direct payments? *
Yes
No
N/A
Mark N/A, if your BIA approved document does not authorize direct pay.
My invoice mailing address needs to be changed. Please update my invoice address to:
The content of this document may contain Sensitive But Unclassified (SBU) data and/or Controlled Unclassified Information (CUI).