TN 15 (08-05)
GN 02403.130 Completing Form SSA-1395-BK (Manual Receipt)
A. Policy - SSA-1395-BK (Manual Receipt)
An SSA-1395-BK receipt will only be completed for out-of-office receipting or during periods when automated receipts cannot be produced. An SSA-1395-BK receipt will be issued to acknowledge the following:
Title II Retirement, Survivors or Disability Insurance (RSDI) returned checks or refunds;
Title XVI Supplemental Security Income (SSI) returned checks or refunds;
Title XVIII Supplemental Medical Insurance (SMI) premium payments;
Returned Medicare checks or Medicare overpayment refunds; and
Any other remittance, e.g., fees, gifts, etc., received in the FO.
B. Process - Issuing Receipt
The interviewer will have sole responsibility for completing the SSA-1395-BK receipt. As soon as the automated system can be accessed, the interviewer:
enters the remittance into the automated system with the SSA-1395-BKs receipt number in the Remittance ID field.
attaches the resulting automated receipt to the SSA-1395-BK receipt and
annotates the automated receipt number on the SSA-1395-BK receipt.
See MSOM DMS 003.006 for instructions on initially entering remittance information into the automated system and the generation of the automated receipt.
C. Exhibit - Form SSA-1395-BK
View PDF Version
D. Procedure - Completing the SSA-1395-BK
Use the following guide to complete each field on the SSA-1395-BK receipt.
Each receipt has an original and one copy. Regardless of the type of remittance, the copy is always given to the remitter and the original always remains in the SSA-1395-BK receipt book.
Enter the date the payment is received.
2. NAME OF BENEFICIARY/RECIPIENT
a. Payment-Title II, XVI or XVIII
If payment is for Title II, XVI or XVIII, enter the name of the beneficiary or recipient on whose record the payment will be applied. If payment is for multiple beneficiaries/recipients (e.g., nursing home, institution, or group residence refunding for several residents), enter See Attached, and:
Annotate on a separate paper the name, SSN, BIC or SSI establishment date, amount of each refund, reason and trust fund.
Prepare an original and one copy of this list.
Give the copy of the attachment to the remitter with the copy of the SSA-1395-BK receipt.
Use the original list to enter the information into the automated system.
is a gift from a known donor, enter the donor's name.
is an anonymous gift, enter anonymous donor.
3. SOCIAL SECURITY NUMBER
is for one beneficiary, enter the SSN on which the payment should be credited.
is for multiple beneficiaries/recipients, enter See Attached.
REFERENCE: See NAME OF BENEFICIARY/RECIPIENT block above for additional information.
is for a Title II beneficiary, enter the beneficiary identification code.
is for a Title XVI beneficiary, leave this block blank.
REASON: The Title XVI Recipient Code is no longer used for keying purposes.
REFERENCE: See NAME OF BENEFICIARY/RECIPIENT block above.
5. CHECK OR MONEY ORDER NUMBER
Enter check number for all personal checks, cashiers checks, bank drafts and government checks (only the last eight digits of a government check). Also, enter the money order number, if applicable.
Check the block if the remittance is cash.
REFERENCE: See GN 02403.009, Processing Cash Remittances Received in the FO, for further information.
Enter dollar and cent(s) amount(s) of the payment(s). If foreign currency, enter amount and type of foreign currency.
8. NAME OF REMITTER
If the remitter:
is the beneficiary/recipient, enter same.
is not the beneficiary/recipient, enter the name of the remitter.
is making an anonymous gift, enter anonymous donor.
is unknown, enter name unknown.
9. DATE OF CHECK OR M.O.
Enter the date of the check or money order, if applicable.
10. REASON FOR PAYMENT
REFERENCE: Title II Returned Check Codes, GN 02405.010E.; Title XVI Returned Check Codes, GN 02405.105A.
is for an overpayment, enter an “X “in the O/P block.
is for misused funds, enter an “X” in the OTHER block and write Misused Funds in the Remarks section.
is for misapplied funds, enter an “X” in the OTHER block and write Misapplied Funds in the Remarks section.
is for conserved funds, enter an “X” in OTHER block and write Conserved Funds in the Remarks section.
is received with an annual report, enter an “X” in ANN. RPT. block.
is a premium, enter an “X” in PREM block.
is a gift and is from a known donor, enter an “X” in OTHER block and write “unconditional money gift or bequest to the (specify) Trust Fund/General Fund of U.S. Treasury” in the Remarks section.
is a gift and is from an anonymous donor, enter an “X” in OTHER block and write “anonymous money gift to (specify) Trust Fund/General Fund of U.S. Treasury” in the Remarks section. DMS does not allow you to key a specified Trust Fund for a gift.
is a fee for documents, enter an “X” in FEE block.
is a fee for forwarding a letter, enter an “X” in FEE block and, write Letter Forwarded or Letter NOT Forwarded as appropriate in the Remarks section.
is for court ordered restitution, enter an “X” in OTHER block and Court Ordered Restitution in the Remarks section.
is a returned Medicare contractors check, enter an “X” in OTHER block and write Returned Medicare Check in the Remarks section.
is for Medicare benefit overpayment, enter an “X” in OTHER block and write Medicare Overpayment in the Remarks section.
is for claimant representative fee refund, enter an “X” in the OTHER block and write Claimant Representative Fee Refund in the Remarks section.
represents Medicare premium payment (Title XVIII), enter an X in the SMI block.
is a Retirement and Survivors Insurance Remittance, enter an X in the RSI block.
is a Supplemental Security Income (Title XVI) remittance, enter an X in the SSI block.
is a Disability Insurance (Title II) remittance, enter an X in the DI block.
If it is not known what the payment represents (Unknown, Medicare benefit, or Prouty), enter an X in the OTH block, and write UNKNOWN, MEDICARE or Prouty in the Remarks section.
12. RECEIVED BY/TITLE/FIELD OFFICE
Enter your name, title, and the field office code in the corresponding boxes.
13. After Remittance is Entered into DMS
After the remittance is entered into DMS, write the systems generated receipt number on the top of the SSA-1395.