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:
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Annotate on a separate paper the name, SSN, BIC or SSI establishment date, amount
of each refund, reason and trust fund.
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Prepare an original and one copy of this list.
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Give the copy of the attachment to the remitter with the copy of the SSA-1395-BK receipt.
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Use the original list to enter the information into the automated system.