Social Services Assessment and Evaluation

Bureau of Indian Affairs Social Services Assessment and Evaluation Individual Indian Monies (IIM)

PART 1: ACCOUNT HOLDER ASSESSMENT

1.1. Identifying Information: Name: AKA’s: Last First MI

Gender: Male Female DOB: ____SSN: ______Marital Status: ______

Tribe of Enrollment: ______Enrollment Number: #______

Mailing Address: ______

Physical Address: ______

Phone: ______Contact/Msg Number: email:

Purpose of Assessment and Summary Recommendation:

Mother’s Name: Father’s Name: DOB: DOB: Tribal Enrollment: Tribal Enrollment: Enrollment Number: Enrollment Number: Physical Address: Address: Mailing Address Phone/Msg Number: Phone/Msg Number: Email: Email:

Other Caretaker: Other Caretaker: Relationship to Relationship to Account Holder: Account Holder: DOB: DOB: Tribal Enrollment: Tribal Enrollment: Enrollment Number: Enrollment Number: Address: Address:

Phone/Msg Number: Phone/Msg Number: Email: Email:

1.2. Legal Information: 1

Is there a court order: Yes No Issuing Court: Date of Order:

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

Name of Guardian/POA/Custodian: Relationship:

Comments:

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

Account holder resides: Independently Parental Home Supervised Setting Relative Care Other How verified:

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

Comments:

b. Family History:

c. Developmental/Cognitive/Education:

d. Medical/Behavioral Health:

e. Activities of Daily Living:

f. Environmental Factors:

g. Employment History:

h. Support Networks:

i. Other General Welfare:

1.4. Resource & Expense Information:

2 *Complete the table below for all resources available to the accountholder. Minor accounts must include an evaluation of resources available to parent(s)/guardian(s)/caretaker(s). RESOURCE TABLE Resource Amount Received Resource Amount Received Bi-weekly Supplemental Security Bi-weekly Wages/ Salary Monthly Income (SSI) Monthly Annually Annually Other Other Bi-weekly Bi-weekly Alimony/ Child Support Monthly TANF Monthly Annually Annually Other Other Bi-weekly Food Stamps Bi-weekly Gifts/ Contributions Monthly Monthly Annually Annually Other Other Bi-weekly Bi-weekly Income Tax Refund Monthly Commodities Monthly (Federal/State) Annually Annually Other Other Bi-weekly Bi-weekly Insurance Settlement Monthly Foster Care Payments Monthly (Auto Accident, etc) Annually Annually Other Other Bi-weekly Social Bi-weekly Interest/ Dividends (Bank Monthly Security/Survivor/Disability Monthly Accounts) Annually Benefits Annually Other Other Bi-weekly Bi-weekly Unemployment Lease Income (list) Monthly Monthly Benefits Annually Annually Other Other Bi-weekly Bi-weekly Lottery/ Gaming Income Veteran’s Benefits/ Monthly Monthly (cash winnings) Payments Annually Annually Other Other Bi-weekly Bi-weekly Retirement Benefits/ Worker’s Compensation Monthly Monthly Pensions Benefits Annually Annually Other Other Bi-weekly Bi-weekly Royalties Monthly Farm/ Ranch Income Monthly Annually Annually Other Other Bi-weekly Bi-weekly Tribal Per Capita Monthly Medicaid/Medicare Monthly Payments Annually Annually Other Other Bi-weekly Bi-weekly Home Health Care Monthly Other (list) Monthly Annually Annually Other Other Total Resources Available: $

Has a representative payee been appointed for any resources identified above: Yes No

Payee: ______Relationship: ______Phone:

3 Comments:

*Complete the table below for all household expenses EXPENSE TABLE Expense Amount Due Expense Amount Due Bi-weekly Bi-weekly Monthly Monthly Rent/Mortgage Child Support Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Utilities-Electricity Insurance-Health Annually Annually Other Other Bi-weekly Bi-weekly Heating-Propane/Fuel Monthly Monthly Insurance-Auto Oil Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Groceries - Communications Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Water-Sewer Loan-Auto Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Garbage Services Loan- Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Transportation Prescriptions/Medications Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Household Supplies Other- Annually Annually Other Other Bi-weekly Bi-weekly Monthly Monthly Personal Supplies Other- Annually Annually Other Other Total Expenses:

Comments:

*Please provide IIM account information in the table below: 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:

4 1.5 Collateral Contacts: (Expound on who contacted, date contacted)

a. Representative Payee: b. Social Worker: c. Medical Provider: d. School: e. Legal: f. Other

1.6 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 Worker Date

Upon review of the assessment and supporting documentation, it is my determination BIA; will will not restrict 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-

5 Assessment and Evaluation sent to applicable parties. Date Sent:

Distribution Plan sent to applicable parties. Date Sent:

PART 2: EVALUATION OF NEEDS AND DISTRIBUTION REQUEST This section will focus on the basis of the distribution requests Account Holder: ______2.1 Request:

Statement of Need(s) Requested Date of Requested by Approximate Recommendation Request Cost 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

2.2 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 a recommendation is made to approve requested items, the table below must be filled out for each item: Disbursement made to Entity Type Disbursement Receipt Responsible party for receipts Due Date related to Required 1. Individual Health Yes Custodian Education No Legal Guardian Welfare Third Party Vendor Other 2. Individual Health Yes Custodian Education No Legal Guardian Welfare Third Party Vendor Other 3. Individual Health Yes Custodian Education No Legal Guardian Welfare 6 Third Party Vendor Other 4. Individual Health Yes Custodian Education No Legal Guardian Welfare Third Party Vendor Other 5. Individual Health Yes Custodian Education No Legal Guardian Welfare Third Party Vendor Other 2.3 Recommendation and Certification:

It is recommended that a 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 Initial Distribution Plan: ______

Prepared by: ______

Signature and Title Date

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 Official Date

I certify that I have been consulted and agree to the terms of the evaluation and distribution plan. Name of Custodian/Guardian:

Custodian/Guardian Date

Attachments: Invoice(s) of estimated costs for requested item(s) Letters supporting disbursement

7 PART 3: DISTRIBUTION PLAN MODIFICATION EVALUATION

Account Holder:

Modification #:

3.1 Statement of Needs Request

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

Statement of Need(s) Requested Date of Requested by Approximate Recommendation Request Cost 1. Approved Partial Approval Not Approved 2. Approved Partial Approval Not Approved 3. Approved Partial Approval Not Approved

3.2 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)

3.3 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 Receipt Responsible party for receipts Due Date related to Required Individual Health Yes Custodian Education No 8 Legal Guardian Welfare Third Party Vendor Other Individual Health Yes Custodian Education No Legal Guardian Welfare Third Party Vendor Other Individual Health Yes Custodian Education No Legal Guardian Welfare Third Party Vendor Other 3.4 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 Title Date

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 Official Date

I certify that I have been consulted and agree to the terms of the evaluation and distribution plan. Name of Custodian/Guardian:

Custodian/Guardian Date

Attachments: Invoice(s) of estimated costs Letters supporting disbursement

9 Addendum sent to applicable parties; Date sent:

Distribution plan modification sent to applicable parties; Date sent: