The FMS-3858 is Treasury’s claims document cover sheet for form Claim Against the United States for the Proceeds of a Government Check (FMS-1133) and check photocopies. Treasury produces this form upon receipt of a nonreceipt or stop payment input. Treasury posts the form to the Treasury Check Information System (TCIS) for printing, if necessary. This form contains essential information about the check:

• •

  Check number,

• •

  Symbol,

• •

  Amount,

• •

  Date,

• •

  Payee's name, address,

• •

  Stop code input by SSA, and

• •

  Treasury's status code response

IMPORTANT: Before forwarding any completed packages to Treasury, make sure the FMS-3858 and FMS-1133 match the check photocopy by comparing check number, symbol, amount and date.

The FMS-1133 is a computer-generated form, consisting of two pages (one sheet, front and back), attached behind the FMS-3858. It contains specific questions pertaining to the receipt and cashing of the missing check. Treasury generates this form when a check payee alleges nonreceipt. The beneficiary, recipient or representative payee completes this form when they allege noninvolvement in the negotiation of the original, courtesy, replacement, or settlement check and contains specific questions pertaining to the receipt and cashing of the missing check.

If the check is still outstanding, the technician should input a non-receipt action to have Treasury issue a courtesy disbursement check, if the check is less than 12 months old. If check is more than 12 months old, follow limited payability procedures in GN 02401.905.

Treasury will credit the amount of payment back into the SSA trust fund when the beneficiary or recipient returns a payment. Treasury reclaims the money from the death of beneficiary or payee. When the technician exhausts all efforts to locate the credit for the physical check, call Fiscal Service at (855) 868-0151 for assistance. This includes examination of all queries and document in the processing centers or field offices. Treasury will not supply information based upon the SSN. You must have the check symbol and check number available prior to making the call.

If the investigation was within the last year, Treasury may provide the information immediately.

Example of follow up for an outstanding check:

You receive an inquiry for an outstanding check dated 1/3/16 and you have exhausted all efforts to locate the credit. Access the Treasury Check Information System (TCIS) to obtain the necessary information concerning the credit. If you cannot access TCIS, call Treasury at (855) 868-0151 for assistance.

TCIS or the Treasury contact will provide you with status and credit information. Take the following actions:

• •

  Use the information to post the credit via the SSA-4208 (Limited Payability Determination)..

• •

  If Treasury does not provide a document number for the SSA-4208, input all sevens (7) in this field.

• •

  If Treasury states the credit is still outstanding, determine if the accounts receivable system (ARS) still has a control for the credit. If so, note no action necessary (NAN) for the inquiry.

• •

  If the investigation is older, Treasury may have to recreate the record. When first contacting Treasury on older cases, Treasury may advise they have no record on their system. However, if payment history update screen (PHUS) shows the stop payment successfully processed (the Treasury department status code (TDSC) is not an exception code), explain the case is old and the record may have to be recreated. You must allow Treasury three workdays to recreate the record before calling back. Treasury will not contact you, recreated records stay online about two weeks, so it is important for you to follow up with Treasury after that three-day timeframe.

• •

  If a physical, document is required (such as a photocopy of check), call Treasury and request that they mail the document directly to you, and expect the document within 10 to 15 workdays. Request Treasury to place your name and module number on the outside of the envelope to ensure timely delivery, establish a 30-day diary.

NOTE: It is never appropriate to use direct input as a method of follow-up on any successfully processed investigation. Contact Treasury at (855-868-0151) for assistance.

IMPORTANT: If completion of the FMS-1133 is not possible review GN 02406.300

1. 1. 

   If completion of an FMS-1133 is necessary in a non-receipt claim but the payee is now deceased have the form completed by an individual eligible to receive an underpayment per

   1. a. 

      GN 02301.030 Underpaid Person is Deceased, and

   2. b. 

      SI 02101.003 SSI Underpayment Due Individual Deceased-General

2. 2. 

   If no individual is eligible to receive an underpayment, and we need a forgery determination,

   1. a. 

      Write "N/A" in the blanks for questions 1-8 on the FMS-1133 and

   2. b. 

      Sign your name and position title on the bottom of the FMS-1133.

3. 3. 

   Obtain signature samples from the date of the check, such as gasoline receipts, cancelled personal checks, tax returns, and attach them to the FMS-1133 with a note explaining why the payee (deceased) does not sign the FMS-1133. Send to the address in GN 02406.160H in this section.

If the case meets the criteria in GN 02401.901, and the limited payability claim is appropriate:

1. 1. 

   Follow the procedures outlined in Handwriting Analysis Needed on a Limited Payability Case GN 02401.910.

2. 2. 

   Review the form for content using criteria in the sample GN 02406.160 in this section.

Occasionally, Treasury requires additional signature specimens to determine forgery. These circumstances might include:

• •

  Limited payability case where check in question was endorsed several years ago; for more information see, Handwriting Analysis Needed on a Limited Payability Case GN 02401.910

• •

  Claimant who filed non-receipt is now deceased and unable to complete an FMS-1133 (although the FMS-1133 can be completed by a family member, signature specimens are still necessary).

Obtain this information from a review of the claims folder if available, from around the time of the issue date of the check, and by asking for copies of cancelled checks or other examples of claimant's signature from the pertinent time period.

Call Treasury's general number (855-868-0151) and explain the problem.

• •

  If the check would not become a limited payability issue, Treasury will advise you to input a K-stop (photocopy request) for the check(s) needed.

• •

  If limited payability is an issue, Treasury will request the check photocopies to complete the claim form (provide check number and symbol at the time of the request).

For those who have access to it, the TCIS can provide a check image for checks.

The CDN is a computer generated form and does not have a form number. Based on the information on the FMS-1133, the CDN provides this information:

• •

  Whether forgery was determined to be a factor or not;

• •

  If additional information is needed to make the forgery determination (e.g., additional signature specimens from around the time the check was issued);

• •

  Treasury's recommended action on the case (e.g., “Claim valid but settlement not appropriate, based on your recertified or non-entitlement stop. Treasury will credit your account when refund is received.”)

Review CDNs to determine action if:

• •

  Treasury needs additional information respond promptly so the investigation can be completed;

• •

  Treasury determines that forgery was involved, review records to determine whether claimant is due a payment (e.g., in a double check negotiation (DCN) situation if both checks were forged and no additional funds were issued to claimant for that benefit month);

• •

  Forgery was NOT involved and no protest to Treasury's determination within the 60-day appeal period GN 02406.310, and DCN is involved start overpayment recovery.

When a Title II beneficiary comes into the field office for assistance complete the FMS-1133;

• •

  Photocopy the form and send a copy to the appropriate PC for their records, and

• •

  Mail the original to Treasury at the address provided. Do not mail to the PC or CO.

• •

  Instruct the payee to use the envelope Fiscal Service provides or use the following address:

  Department of the Treasury
  Bureau of the Fiscal Service
  P.O. Box 515
  Philadelphia, PA 19105
• •

  Diary for 90 days for return of the CDN from Treasury;

• •

  Obtain status of the case through TCIS or call Treasury at 855-868-0151.