TN 43 (09-23)

DI 39506.251 Preparation Instructions for Form SSA-871

A. Procedure - form heading

Enter official name of the agency, State, fiscal year, and reporting period in the designated space.

B. Procedure - report columns

1. Column (a) - Description of Equipment

Enter description of equipment under category for which disbursements have been made during the quarter being reported. At the present time there should be no purchases for EDP equipment.

2. Column (b) - Type of Approval

For each item listed under Equipment and Upgrades, enter the type of authority approved for the purchase:

  • Enter “R” if the item was approved under SSA regional office (RO) authority for all equipment over $5,000

  • Enter “D” if the item was purchased under DDS line item authority for equipment under $5,000

3. Column (c) - Date of Approval

Each regional office has authority to approve equipment purchases contingent on whether the requests meet the criteria for a critical or emergency need and must be within existing DDS operational funds.

DDS authority

Each DDS has authority to purchase equipment. The criteria for this DDS authority follows:

The purchase must be within existing operating funds and cannot have any fiscal impact on the state's ability to process their budgeted workload.

The DDS must inform SSA regional office with a description and cost of purchase to obtain a line item.

4. Column (c) - Date of Approval

Enter the date funding was approved for each item listed under RO authority. Enter date of purchase for each item listed under DDS authority.

5. Column (d) and (e) - Number of Units (Additional/Replacement)

List the number of units in the appropriate column, (d) additional or (e) replacement.

6. Column (f) - Unit Cost

Enter the unit cost for each item listed in column (a). The unit cost should include taxes, delivery, and installation costs.

7. Column (g) - Gross Cost

This column should reflect the gross cost for each item listed in column (a)--derived by multiplying the number of items in column (d) or (e) by the unit cost, column (f).

8. Column (h) - Trade-in Value, If Replacement Item

Enter the expected value of items being traded with purchase of units shown in column (e).

9. Column (i) - Net Cost *

This column should reflect the Net Cost of each item listed in column (a)—derived by subtracting the trade-in value (amount shown in column h) from the gross cost (amount shown in column g).

C. Procedure - line item reporting

Enter description of other equipment (excluding EDP equipment/upgrades) for which disbursements have been made during the quarter being reported, see DI 39506.210D.4.e.

D. Procedure - total net cost of equipment

This line should reflect the total Net Cost of equipment listed in column (a) derived by adding the amounts shown in column (i).

E. Procedure - signature and date

Sign and date Form SSA-871.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0439506251
DI 39506.251 - Preparation Instructions for Form SSA-871 - 09/26/2023
Batch run: 09/26/2023
Rev:09/26/2023