Forms Appendix 400-17-115


SFN 413, "Individual Indian Monies Account" 400-17-115-05

(Revised 7/01 ML #2697)

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The purpose of SFN 413, "Individual Indian Monies Account" (IIM), is to obtain definite information from Indian agencies about deposits made to and balances remaining in IIM Accounts. This information is necessary to determine eligibility and benefit amount and lends itself to prorating based on income received during a previous 12-month period.


The upper portion of the form is to be completed by the worker. The form must be signed by the applicant/recipient who then sends or takes it to the superintendent of the Indian agency for completion. Or, the household may choose to sign a Release of Information permitting the county social service office to obtain the needed data from the Indian agency directly. SFN 413, signed by the applicant/recipient, must also be used when this method is followed.


The bottom portion of the form is completed by appropriate officials of the Indian agency.


IIM accounts for persons enrolled at the Fort Totten and Turtle Mountain Indian agencies are maintained in the Aberdeen, South Dakota, Area Office. Accounts for persons enrolled by the Fort Berthold and Standing Rock agencies are maintained by each of those agencies.


This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (71kb pdf)


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