TN 28 (03-18)

A. List of the UTIS used on the Payment Stub

List of the UTIs used on the Payment Stub shown below in their order of sequence. The Payment Stub is not generated when PCOC is 8.

1. BLSH11 – BLANK LINE

THIS UTI CREATES A BLANK LINE FOR PRINTING PURPOSES

2. BLS100 – HEADING FOR PAYMENT STUB

PAYMENT STUB (appears in center of page)

3. BLS034 – HOW TO REFUND OVERPAYMENT

• Return the bottom portion of the stub with your payment.

• Use the enclosed envelope to mail your payment to us

• Do not send cash.

4. BLS102 – PCOC 1 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Northeastern Program Service Center, PO Box 314400, Jamaica NY 11431-9887.

5. BLS103 – PCOC 2 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Mid-Atlantic Program Service Center, 300 Spring Garden Street, Philadelphia PA 19123.

6. BLS124 – PCOC 3 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Southeastern Program Service Center, 1200 Rev Abraham Woods, Jr Blvd, Birmingham AL 35285-0001.

7. BLS105 – PCOC 4 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Great Lakes Program Service Center, Harold Washington Social Security Center, 600 W. Madison Street, Chicago IL 60661-2474.

8. BLS106 – PCOC 5 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Western Program Service Center, PO Box 4055, Richmond CA 94804-9941.

9. BLS107 – PCOC 6 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Mid-America Program Service Center, PO Box 15531, Kansas City MO 64106-9701.

10. BLS108 – INFORMATION ON ADDRESS, CREDIT CARD AND CONTACT NUMBERS

• If you have changed your address or telephone number, be sure to check the box below and write your new address or telephone number in the space provided.

• If you pay by check or money order, include (1) Social Security claim number and make the check or money order payable to "Social Security Administration."

• If paying by credit card, complete the appropriate information below and return it in the enclosed envelope

                                     OR

to pay by phone, call (2) during the hours (3) . Please have this notice and your credit card available when you call.

11. BLS119 – PCOC 7 ADDRESS

• Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Office of Central Operations, 1500 Woodlawn Drive, Baltimore MD 21241-1500.

12. BLS109 – BLANK LINE

THIS UTI CREATES A BLANK LINE FOR PRINTING

13. BLS069 – SSA FORM NUMBER IN THE DETACHABLE PART OF PAYMENT STUB

SSA-53-EP - DETACH HERE. DO NOT STAPLE.

14. BLS011 – BLANK LINE

THIS UTI CREATES A BLANK LINE FOR PRINTING

15. BLS112 – ACCOUNT NUMBER AND CREDIT CARD SELECTION

ACCOUNT NUMBER: (1) []MASTERCARD []VISA []DISCOVER

16. BLS113 – NAME, CREDIT CARD, EXPIRATION DATE

(1) Credit Card Number Exp Date

17. BLS114 – OVERPAYMENT AMOUNT DUE

AMOUNT DUE: (1)

18. BLS066 – OVERPAYMENT DUE DATE

DATE DUE: (1)

19. BLS067 – PAYMENT AMOUNT, SIGNATURE, COA

PAYMENT                      Cardholder's Signature             Date

AMOUNT $__________     _____________________     _________

Check box if your address or [] telephone number has changed.

Make changes below.

20. BLS068 – PAYMENT ADDRESS

SOCIAL SECURITY ADMINISTRATION

PO BOX 3430

PHILADELPHIA, PA 19122-9985

21. BLS060 – SCAN LINE

The scan line contains information automated by the T2R notice process and used by Philadelphia when scanning in the detachable payment stub.

22. ACT003 – PRIVACY ACT STATEMENT (PRINTED ON THE BACK OF THE PAYMENT STUB)

Privacy Act Statement

The Social Security Administration (SSA) has authority to collect the information requested on the PAYMENT STUB under section 204 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out the credit card information if you choose another means of payment (for example, by check or money order).

If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA's account. This will allow you to repay your overpayment with your credit card. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security office.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.