TN 17 (01-13)

A. Introduction to the Fee Transmittal Register

The Form SSA-414-U3 (Fee Transmittal Register) provides a control and audit trail for fees mailed from the Field Office (FO) to the Office of Finance (OF) or to Office of Earnings Operations (OEO). For information on processing fees received in the FO, see GN 02403.012.

B. How to use the Fee Transmittal Register

The remittance clerk prepares the SSA-414-U3 during the same time he or she reconciles all the receipts issued that day. The remittance clerk will reconcile the fee information recorded in the Debt Management System (DMS) and displayed on the FO Daily Receipt Listing (FODRL) against the receipts issued that day. For an explanation of the FODRL, see GN 02403.021.

1. When to use the SSA-414-U3

The FO only uses the SSA-414-U3 to transmit and control fees (checks, money orders, and credit card authorization forms) from the FO to OF or OEO. The FO must complete a separate SSA-414-U3 for fees they send to OF or OEO.

2. When not to use the SSA-414-U3

The FO does not use the SSA-414-U3 to transmit any other type of remittance, e.g., do not use for Centers for Medicare and Medicaid Services (CMS) lockbox premiums or attorney fee remittances.

C. References

• Controlling and Following Up on Fee Transmittal Registers (SSA-414-U3) for Fees Sent to Office of Finance (OF) and Office of Earnings Operations (OEO), GN 02403.055

• Processing Medicare Premium Remittances Received in the FO, GN 02403.030

D. Exhibit of Form SSA-414-U3 (Fee Transmittal Register)

 View PDF Version

E. Procedure for the Fee Transmittal Register

Obtain entries from the FODRL. The following explains how to complete each field on the SSA-414-U3.

IMPORTANT: Only the remittance clerk or backup should complete the SSA-414-U3.

1. TO:

Check the OEO or OF box, for information to determine the destination of the fee, see GN 02403.012B and GN 02403.012C.

2. DATE

Enter the date you are preparing the register.

3. SOCIAL SECURITY NUMBER

Enter the SSN from “ACCT ID” on the FODRL. If multiple services are involved for one fee, enter “See Attached” and attach an explanation of the fee payment.

4. NAME OF REMITTER (FIRST) (LAST)

Enter the first name and last name of the remitter or the entity requesting the information.

5. $ AMOUNT

Enter the dollars and cents from the “Remittance Amount” on the FODRL.

6. RECEIPT NUMBER

Enter the receipt number from “RECEIPT #” on the FODRL.

7. CHECK OR MONEY ORDER NUMBER

Enter the check number or the first four digits of the money order for the fee. If the remitter paid the fee by credit card, enter “CC.” Do not enter the credit card number.

8. SERVICE REQUESTED

Enter what the fee is for. Make your statement clear.

9. TOTAL $ AMOUNT

Enter the cumulative dollars and cents of the fees attached to this page. Make sure the amount corresponds to the total amount of fees attached. If possible, and when there is a large number of fees, attach an adding machine tape to substantiate the total amount.

10. REMARKS

Enter any additional pertinent information regarding the fees collected. Do not enter the credit card number.

11. FO CODE

Enter the FO Code of the FO completing the form.

12. SIGNATURE OF REMITTANCE CLERK

The remittance clerk must sign his or her name.

13. SIGNATURE OF SUPERVISOR

Remittance supervisor must review and sign his or her name.

14. PHONE NO. (Required)

Remittance supervisor must enter his or her phone number.

15. FAX NUMBER

Enter the FO fax number.

16. FROM

Clearly stamp or write the complete FO address so OF or OEO can return the original SSA-414-U3 to the FO as verification that they received the remittance. Neither OF nor OEO clerks will call for the address.

17. AUTHORIZED SIGNATURE

The management designated SIGNATURE person who reviews and affirms the accuracy of the register.

18. PRINT NAME

The OEO or OF supervisor must print his or her full name.

19. PHONE NO.

The supervisor must enter his or her phone number.

20. DATE

The date OF or OEO sent the check for deposit.