TN 25 (07-11)

GN 02406.147 Handling a Request for Certified Payment Extracts

A. Introduction to certified payment extracts

The certified extract is a record of payments used as a legal document in a court of law. Certified payment extract (CPE) requests may derive from local courts, private sector attorneys, or other entities seeking verification of benefit information for child support enforcement cases or food stamp fraud. Most requests come from the Office of the Inspector General (OIG). Certified payment extract requests are priority and should be handled within twenty business days of receipt.

B. Request for payment extracts from local courts, private sector attorneys, or other entities

To prepare correspondence for a payment extract follow these instructions for the format and required information. Exact style may vary in the different processing centers and components.

Prepare the following:

  • Cover memorandum. Follow the instructions in Exhibit 2 GN 02406.147F ;

  • Authorization for certification of extract (Swear Statement); follow the instructions in Exhibit 3 of GN 02406.147F;

  • Certified payments extract use the format shown in Exhibits 4 and 5 GN 02406.147F.

Include the following items in the correspondence:

  1. A short introductory paragraph that includes the beneficiary's name and timeframe covered by the extract;

  2. The payment history including:

    • Issue date of the check

    • Exact amount of payment

    • Explanation of the check represented payment for the stated period

    • Extract of data relating to negotiated checks only

    • Do not include non-negotiated checks in the extract (i.e. a returned check)

    • Include hospital insurance and supplemental medical insurance (HI/SMI) explanation when there is a change in HI/SMI

  3. Annotate the check range in the “represented Payment for” column for all prior month accruals (PMA) and critical payments (CPS);

  4. Explain any check that represented an overpayment;

  5. If the beneficiary identification code (BIC) involved has a payee change include the dates of the change in the opening paragraph;

  6. If a financial institution is involved show the name and address of that institution;

  7. Mail or fax completed request to the regional office address listed under GN 02406.147D.

C. Processing Title II requests for certified payment extracts

OIG requests certified extracts for use in prosecuting Title II fraud. These extracts are acceptable as evidence at fraud hearings in lieu of certified photocopies of checks and of testifying by the SSA official identified as the keeper of record.

OIG submits requests for all Title II extracts from the corresponding Payment Service Center’s Regional Center for Security and Integrity (CSI) in writing. You can identify these extract requests by the CSI flag, see Exhibit 1 GN 02406.147F. For OIG requests, the CSI will distribute copies of the extract; provide address of the OIG contact requesting the extract and a reference number, if applicable.

D. Title II payment extract request addresses

Mail or fax completed request to the regional office address listed below.

Region 2: New York (NEPSC)

Social Security Administration

Center for Security and Integrity

26 Federal Plaza

Room 40–160A

New York, NY 10278

Telephone: (212) 264-2604

Fax: (212) 264-0916

    

Region 3: Philadelphia (MATPSC)

Social Security Administration

Office of the Regional Commissioner

Center for Security and Integrity

Attn: Carmen Butler

PO Box 8788

Philadelphia, PA 19101

Telephone: (215) 597-1014

Fax: 215-597-5203

Region 4: Atlanta (SEPSC)

Social Security Administration

Center for Security and Integrity

Birmingham Social Security Center

1200 Rev. Abraham Woods Jr. Blvd.

Birmingham, Alabama  35285

Fax: (205) 801-1332

     

Region 5: Chicago (GLPSC)

Social Security Administration

Center for Security and Integrity

P.O. Box 87479

Chicago, IL 60680

Telephone: (312) 575-4120

Fax: (312) 575-4121

   

Region 7: Kansas City (MAMPSC)

Social Security Administration

Center for Security and Integrity

MAMPSC

PO Box 15625

Kansas City, MO 64106

Telephone: 816-936-5555

Fax: 816-936-5573

     

Region 9: San Francisco (WNPSC)

Social Security Administration, SFRO

Center for Security and Integrity, 2nd FL

PO Box 4206

San Francisco, CA 94804

Fax: 510-970-2644

     

Mail or fax completed requests for PC7 and PC8 to the address listed below.

Office of Central Operations (PC7 or PC8)

Social Security Administration

Office of Central Operations

Center for Security and Integrity

1500 Woodlawn Drive

PO Box 32921

Room 7040 SWT

Baltimore MD 21241

Fax: 410-597-0140

Email: ||OCO Integrity Branch

E. Processing Title XVI request for certified payment extracts

To request Title XVI payment extracts, complete the request letter as appropriate, see GN 02406.147D. Mail or fax information to the regional office of jurisdiction at the following address:

Region 1: Boston

Social Security Administration

JFK Federal Building

Room 1925

Boston, MA 02203

Fax: (617) 565-9359

 Region 2: New York

Social Security Administration

Center for Programs Support

26 Federal Plaza

Room 4060

New York, NY 10278

Telephone: (212) 264-4004

Fax: (212) 264-2071

  

Region 3: Philadelphia

Office of the Regional Commissioner/Seventh Floor

Center for Programs Support

P.O. Box 8788

Philadelphia, PA 19101

Fax: (215) 597-2989

  

Region 4: Atlanta

Social Security Administration

Center for Programs Support

Atlanta Regional Office

Suite 22T64

61 Forsyth Street, S.W.

Atlanta, GA 30303-8907

Fax: (404) 562-1325

   

   Region 5: Chicago

CRSI/SSI

PO Box 8280

Chicago, IL 60680-8280

Fax: (312) 575-4245

  

 Region 6: Dallas

SSA, MOS, CPS, SSI

1301 Young St, Ste 670

Dallas, TX 75202-5433

Fax: (214) 767-1348

Phone: (214) 767-4224

   

   Region 7: Kansas City

Center for Programs Support

ATTN: Certification Request

Room 1073, 601 E 12th St

Kansas City, MO 64106

Fax: (816) 936-5951

   

Region 8: Denver

Social Security Administration - CPS
1001 17th Street
Denver, CO 80202

Fax: (303) 844-4280

  

   Region 9: San Francisco

Social Security Administration, SFRO

Center for Programs Support, 6th Fl

PO Box 4206

Richmond, CA 94804

Fax: (510) 970-8101

Attn: Regional Privacy Act Coordinator

   

Region 10: Seattle

Social Security Administration, SPST

Suite 2900, MS 303A

701 5th Avenue

Seattle, WA 98104-7075

Fax: (206) 615-2643    

F. Example formats for requesting payment extracts

Use these examples as a guide to format your request for payment extracts. OIG uses one form to request payment extract for both Title II and Title XVI.

Exhibit 1 — Form to Request Title II Payment Extract

Request of Title II (SSA) Benefit Payments

   

Send to:

Social Security Administration

Center for Security and Integrity

(Insert the Processing Center of jurisdiction address )

   

Requests involving all Foreign Claims and Disability Claims under Age 55        

Please prepare:

(check one)

        (a) Certified extract (court date scheduled for)
          (b) Extract (no court date scheduled)

of benefits for all payments issued to the following beneficiary (ies) under the following Social Security number(s) during the listed period:

    

Social Security Number (SSN):                          

Beneficiary (ies):

1)         /      

 

2)        /       

 

3)        /      

 

Name                 Own SSN:

Time Period for record of payments (only months/years involved in investigation)

(After 12/83)

From                      Thru:                       

 

       (MM/YY)             (MM/YY)  

 

This request is made as part of an investigation of a possible fraud/violation of the _______________________________________________ program(s).
Case Number: _______________
Name of Requester: _______________
Title of Requester:  _______________ 
Office of Requester: _______________         

Requester Phone NO: _______________                   

Date:  _____________              Signature _____________    

   

 

Exhibit 2 – Cover Memorandum to the Office of Investigation:

Letterhead Memorandum Paper

To

: Requesting Office

From

: Authoring Component

Subject

: 000-00-0000,                     

    

 (Claimant's name), Request for Certified Extract (Request dated ______) (Include reference number in the subject line)          

  

Attached are the authorization for certification of extract records, certified extract of benefits for payments issued to all beneficiaries on this account from _________through__________.

    

Payments certified for the period______through______were for payment via direct deposit to (Bank’s name and address), for deposit to checking/savings account number ______and identified by the routing and transit number
(RTN)                                                    .

  (Complete only if applicable)   

                
(Director's Signature)
  

                
(Director’s Name)

 

Process Division__________
Attachments

   

Exhibit 3 – Authorization for Certification of Extract from records:

     

Baltimore, Maryland 21241
Refer to:              

 (Requesting office Name and Address)

    

CERTIFICATION OF EXTRACT FROM RECORDS

In accordance with provisions of Title 42, United States Code (USC), Section 904, and the authority vested in me by 42 U.S.C. 902. I hereby certify that I have legal custody of certain records, documents, other information established and maintained by the Social Security Administration, pursuant to Title 42, United States Code, Section 405, and that the annexed is a true extract from such records in my custody as aforesaid.

I further certify that all signatures of the Social Security Administration officials on the annexed document(s) are genuine and made in accordance with the signers’ official capacity

IN WITNESS WHEREOF, I have set my hand and caused the seal of the Social Security Administration to be affixed this_______day of_______.

     

     

          
(Director's Signature)

            
(Director's Name)

        

Exhibit 4 – Extract Format

     

Social Security Administration
Refer to: ________

            

To Whom It May Concern:

           

The following Social Security benefits was certified for payment to John Doe and Jane I. Doe under Social Security claim number 000-00-0000 for the period July 3, 1997 through June 3, 1998 and have not been reported as non-receipt items.

     

Approximate Date of Payment

Amount

Represented Payment for

July 3, 1998

$604.20

June 1998 minus supplemental medical insurance premiums of $9.60

August 1, 1997

$604.20

July 1997

September 3, 1997

$604.20

August 1997

October 3, 1997

$604.20

September 1997

November 3, 1997

$604.20

October 1997

December 3, 1997

$604.20

November 1997

January 2, 1998

$604.20

December 1997

February 3, 1998

$604.20

January 1998

March 3, 1998

$638.90

February 1998

April 3, 1998

$638.90

March 1998

May 3, 1998

$638.90

April 1998

June 3, 1998

$638.90

May 1998

 

$7,389.20

Total amount paid to John Doe and Jane I. Doe for July 3, 1997 through June 3, 1998

   

Exhibit 5 – OIG Payment Extract Request Format – Title II and Title XVI

   

Office of the Inspector General
Office of Investigations
Social Security Administration

   

     

Date:         _______

To:             Social Security Administration (Regional Offices addresses)
Fax:

   

     

From:        _______________________________________

                  _______________________________________

   

       

Subject:      Request for: ­­­­­­­­­­­­­­­­­­­­__________________________________________________

RE:            SSA OIG OI File Number (SSN) ________________________________

   

In conjunction with an official investigation being conducted by this office, this is a request for (if requesting payment extract, provide period of time covered):
_________________________
_________________________
_________________________

Please forward the documents identified above to _______________________ at the following address no later than ___________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     (Requester phone number: _____________________) 

      

Exhibit 6 – Request for Title XVI Payment Extract

   

Social Security Administration
Request for Title XVI Payment Extract

   

To: Social Security Administration (Regional Offices addresses)
Fax:

   

From:

  

Subject: Request for: (check one)

   

 ____(a) Certified extract (court date scheduled for) ______ or  ______ (b) Extract (no court date scheduled) of benefits for all payments issued to (Recipient's Name)_____________ , (Payee's Name, if appropriate)____________ , (Recipient's SSN)     ______________ for the period of ________ thru (use MM/YY format).

    

Please forward the materials requested to the following name and address
by__________________.

                                                                    

_______________________________

 

Phone:   ___________________             

 Requester's Signature: _________________                  Date: _______________

    

Thank you for your assistance in this matter.

   

Exhibit 7 – Example of Extract Cover Note

    

Social Security Administration
Regional Office- __________________
Date:

      

    

Special Agent's Name
Special Agent's Title
SSA/OIG
6401 Security Boulevard
Baltimore, MD 21235

   

     

Dear (Agent's Name):

This is in reference to your letter dated ____________, about payments made to ___________(Recipient's Name), Social Security number _____________ for the period _____________ through _______________ . Please see enclosed extract.

     

If you have any further questions regarding this, please contact __________________, Region _____, at _________________ .

    

Sincerely,
(Name)____________
(Title)____________
Regional Office ____________

Enclosure

   

Exhibit 8 – Example of Title XVI Payment Extract

   

Social Security Administration
Regional Office ______________

   

I, _________________________, Social Security Administration, Region ___, hereby certify that the following business system records of the Social Security Administration pertain to the record of (Recipient's Name ) ________________ , Social Security number _________________ .

I further certify the records of the Social Security Administration show that entitlement to the Supplemental Security Income (SSI) payments as of (Date)____________ , under Section 1602 of the Social Security Act were paid to (Recipient's Name) __________________ .

   

Below is the record of the SSI payment for the period you requested. I further certify that the current representative payee is (Representative Payee's Name, when appropriate) ___________________.

   

DATE

AMOUNT

06/01/1990

$418.40

06/02/1990

5548.79

07/01/1990-12/01/1990

418.40 PER MONTH

01/01/1991-12/01/1991

439.40 PER MONTH

01/01/1992-12/01/1992

454.40 PER MONTH

01/01/1993-12/01/1993

466.40 PER MONTH

   

Sincerely,
  
(Name
   
(Title
   
 Regional Office _____________________


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0202406147
GN 02406.147 - Handling a Request for Certified Payment Extracts - 12/07/2017
Batch run: 12/07/2017