Social Services Assessment and Evaluation

Bureau of Indian Affairs

Individual Indian Monies (IIM)

Part I: Account Holder Assessment

Identifying Information:

Name: AKA’s:

LastFirst MI

Gender: Male Female DOB: SSN: Marital Status:

Tribe of Enrollment: Enrollment Number:

Mailing Address:

Physical Address:

Phone: Contact/Msg Number: email:

Mother’s Name: / Father’s Name:
DOB: / DOB:
Tribal Enrollment: / Tribal Enrollment:
Enrollment Number: / Enrollment Number:
Address: / Address:
Phone/Msg Number: / Phone/Msg Number:
Email: / Email:
Other Caretaker: / Other Caretaker:
Relationship to Account Holder: / Relationship to Account Holder:
DOB: / DOB:
Tribal Enrollment: / Tribal Enrollment:
Enrollment Number: / Enrollment Number:
Address: / Address:
Phone/Msg Number: / Phone/Msg Number:
Email: / Email:

Legal Information:

Is there a court order: Yes NoIssuing Court: Date of Order:

Type of order: Guardianship Custody Power of Attorney Non compos mentis Other:

Name of Guardian/POA/Custodian: Relationship:

Does the order list any powers or limitations: Yes No

Comments:

Has the order been reviewed by the Solicitor: Yes No

Has authorization to recognize order been received by the Solicitor: Yes No

Comments:

Assessment Information:
Household Composition:(If account holder resides in supervised setting or relative care, address why, etc.)

Account holder resides: Independently Parental Home SupervisedSetting Relative Care Other

How verified:

Members of Household
(Last, First, MI) / DOB/
Age / Gender / Relationship to Account Holder / Tribal Affiliation
1.
2.
3.
4.
5.
6.
7.
8.

Comments:

Family History:

Developmental/Cognitive/Education:

Medical/Behavioral Health:

Activities of Daily Living:

Environmental Factors:

Employment History:

Support Networks:

Other General Welfare:

Resource Information:

(Minor accounts must include an evaluation of resources for parent(s)/guardian(s)/caretaker(s)) For any items checked, the social worker must obtain documentation.

Resource / Amount / Received / Resource / Amount / Received
Wages/ Salary / Bi-weekly
Monthly
Annually
Other / Supplemental Security Income (SSI) / Bi-weekly
Monthly
Annually
Other
Alimony/ Child Support / Bi-weekly
Monthly
Annually
Other / TANF / Bi-weekly
Monthly
Annually
Other
Gifts/ Contributions / Bi-weekly
Monthly
Annually
Other / Food Stamps / Bi-weekly
Monthly
Annually
Other
Income Tax Refund (Federal/State) / Bi-weekly
Monthly
Annually
Other / Commodities / Bi-weekly
Monthly
Annually
Other
Insurance Settlement (Auto Accident, etc) / Bi-weekly
Monthly
Annually
Other / Foster Care Payments / Bi-weekly
Monthly
Annually
Other
Interest/ Dividends (Bank Accounts) / Bi-weekly
Monthly
Annually
Other / Social Security/Survivor/ Disability Benefits / Bi-weekly
Monthly
Annually
Other
Lease Income (list) / Bi-weekly
Monthly
Annually
Other / Unemployment Benefits / Bi-weekly
Monthly
Annually
Other
Lottery/ Gaming Income (cash winnings) / Bi-weekly
Monthly
Annually
Other / Veteran’s Benefits/ Payments / Bi-weekly
Monthly
Annually
Other
Retirement Benefits/ Pensions / Bi-weekly
Monthly
Annually
Other / Worker’s Compensation Benefits / Bi-weekly
Monthly
Annually
Other
Royalties / Bi-weekly
Monthly
Annually
Other / Farm/ Ranch Income / Bi-weekly
Monthly
Annually
Other
Tribal Per Capita Payments / Bi-weekly
Monthly
Annually
Other / Bank Account/Type of Bank (Savings, Checking, etc.) / Bi-weekly
Monthly
Annually
Other
Home Health Care / Bi-weekly
Monthly
Annually
Other / Bank Account/Type of Bank (Savings, Checking, etc.) / Bi-weekly
Monthly
Annually
Other
Medicaid/Medicare / Bi-weekly
Monthly
Annually
Other / Other (list) / Bi-weekly
Monthly
Annually
Other
Total Resources Available: / $

Has a representative payee been appointed for any resources identified above: Yes No (If yes, social worker must obtain documentation of award letter and appointment letter)

Payee: Relationship: Phone:

Comments:

Expenses: For any items checked, the social worker must obtain documentation.

Expense / Amount / Due / Expense / Amount / Due
Rent/Mortgage / Bi-weekly
Monthly
Annually
Other / Child Support / Bi-weekly
Monthly
Annually
Other
Utilities-Electricity / Bi-weekly
Monthly
Annually
Other / Insurance-Health / Bi-weekly
Monthly
Annually
Other
Heating-Propane/Fuel Oil / Bi-weekly
Monthly
Annually
Other / Insurance-Auto / Bi-weekly
Monthly
Annually
Other
Groceries / Bi-weekly
Monthly
Annually
Other / Communications / Bi-weekly
Monthly
Annually
Other
Water-Sewer / Bi-weekly
Monthly
Annually
Other / Loan-Auto / Bi-weekly
Monthly
Annually
Other
Garbage Services / Bi-weekly
Monthly
Annually
Other / Loan- / Bi-weekly
Monthly
Annually
Other
Prescriptions/Medications / Bi-weekly
Monthly
Annually
Other / Transportation / Bi-weekly
Monthly
Annually
Other
Household Supplies / Bi-weekly
Monthly
Annually
Other / Other- / Bi-weekly
Monthly
Annually
Other
Personal Supplies / Bi-weekly
Monthly
Annually
Other / Other- / Bi-weekly
Monthly
Annually
Other
Total Expenses: / $

Comments:

Trust (IIM)Account / Amount / Source
Lease Judgment Minerals Monthly Resource (SSI, VA)
Other
Lease Judgment Minerals Monthly Resource (SSI, VA) Other
Lease Judgment Minerals Monthly Resource (SSI, VA) Other

Comments:

Collateral Contacts:

(Expound on who contacted, date contacted)

Representative Payee

Social Worker

Medical Provider

School

Legal

Other

Summary of Findings and Recommendations:

Minor Account- Supervision required per regulations

Social worker will provide a succinct summary of findings supporting recommendation:

Based on the assessment it is; recommend not recommend to restrict and supervise this account as an:

Adult in need of financial assistance Adult Non-compos mentis Adult under legal disability Emancipated Minor

Social WorkerDate

Upon review of the assessment and supporting documentation, it is my determination BIA; will will notrestrict and supervise this account.

BIA Official Date

Kennerly Notice sent to: Date sent:

(Notice must be clearly addressed and sent certified mail return receipt requested)

Attachments:

Court Orders Guardianship Annual Reports

Photo ID Behavioral Health Records

Financial Award Letters Resource Documents (Income and Expense of account holder and parental)

Medical Records Other-

Educational Records Other-

Part II: Evaluation of Needs and Distribution Request

This section will focus on the basis of the distribution requests

(Social Worker will be required to complete addendum addressing specific questions for large purchase requests. Such requests include but not limited to: automobiles, houses (trailer), boats, ATV’s, motor home, large medical items). Automobile purchase requests must answer questions pursuant to June 28, 2002 policy memorandum.

Account Holder:

Request:

Statement of Need(s) Requested / Date of Request / Requested by / Approximate Cost / Recommendation
1. / Approved
Partial Approval
Not Approved
2. / Approved
Partial Approval
Not Approved
3. / Approved
Partial Approval
Not Approved
4. / Approved
Partial Approval
Not Approved
5. / Approved
Partial Approval
Not Approved
6. / Approved
Partial Approval
Not Approved
7. / Approved
Partial Approval
Not Approved
8. / Approved
Partial Approval
Not Approved
9. / Approved
Partial Approval
Not Approved
10. / Approved
Partial Approval
Not Approved

Justification:

Social Worker must provide justification for each decision after fully evaluating all other resources, including parental income, available to meet unmet needs. You must be specific and address how it meets the health, education, or welfare of the account holder.

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Disbursement made to / Entity Type / Disbursement related to / Receipt Required / Responsible party for receipts / Due Date
Individual
Custodian
Legal Guardian
Third Party Vendor
Other / Health
Education
Welfare / Yes
No

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Recommendation and Certification:

It is recommended that a distribution plan be: Approved Not approved for the paymentslisted in this evaluation as they are deemed to be in the best interest of the account holder.

Date of Initial Distribution Plan:

Prepared by:

Signature and TitleDate

I approve and certify that the plan is in the best interest of the account holder.

Name of BIA Official:

Signature and Title of BIA OfficialDate

I certify that I have been consulted and agree to the terms of the evaluation and distribution plan.

Name of Custodian/Guardian:

Custodian/GuardianDate

Attachments:

Invoice(s)of estimated costs

Letters supporting disbursement

Part III: Distribution Plan Modification Evaluation

Account Holder:

Modification #:

Request

A request is being made to modify the initial distribution plan developed on to include the following:

Assessment Update

Addendum to Initial Assessment

Please define out specific changes to the account holder’s initial assessment. Capture relevant information pertaining to changes in resources, living situation, and medical. Discuss parameters of modification request

Receipts: Have all receipts been collected for the initial distribution plan?

Yes No NA Other (explain) (If no, social worker cannot proceed further with new requests)

Justification

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Justification:

If recommendation is made to approve the request the table must be filled out for each item requested:

Recommendation and Certification

It is recommended that a modification to the distribution plan be: Approved Not approved for the payments listed in this evaluation as they are deemed to be in the best interest of the account holder.

Date of Modified Distribution Plan: Date Initial Plan Reviewed:

Prepared by:

Signature and TitleDate

I approve and certify that the plan is in the best interest of the account holder.

Name of BIA Official:

Signature and Title of BIA OfficialDate

I certify that I have been consulted and agree to the terms of the evaluation and distribution plan.

Name of Custodian/Guardian:

Custodian/GuardianDate

Attachments:

Invoice(s) of estimated costs

Letters supporting disbursement