Effective Dates: 10/25/2024 - Present Previous | Next

TN 126 (10-24)

GN 02406.160 Description and When to Use Department of the Treasury Forms FS-1133 and FS-3858

This section informs the technicians about the purpose of the forms used or requested by the Department of the Treasury (Treasury), Bureau of Fiscal Service (Fiscal Service). We use these forms to request information or assistance and to resolve nonreceipt check claims filed by beneficiaries, recipients and representative payees for payments issued by the U.S. Government.

A. Claims Document (FS-3858)

The FS-3858 is Treasury’s claims document cover sheet for the form Claim Against the United States for the Proceeds of a Government Check (FS-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:

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Check number,
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Symbol,
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Amount,
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Date,
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Payee's name, address,
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Stop code input by SSA, and
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Treasury's status code response

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

B. Form FS-1133-Claim Against the United States for the Proceeds of a Government Check

The FS-1133 is a computer-generated form, consisting of two pages (one sheet, front and back), attached behind the FS-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 on a negotiated check in A, B, C, G, and F-stop situations. Treasury mails the package directly to the beneficiary, recipient, or representative payee. Treasury also posts the package to the Treasury Check Information System (TCIS). The beneficiary, recipient or representative payee completes this form when they allege non-involvement in the negotiation of the original, courtesy, replacement, or settlement check. The form contains specific questions pertaining to the receipt and cashing of the missing check.

1. Identifying a nonreceipt issue

Interview the beneficiary, recipient or representative payee and review the appropriate master records to determine if the allegation is a true nonreceipt.

If the beneficiary, recipient, or representative payee recognizes the signature as their own:

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Do not send to Fiscal Services.
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Initiate overpayment recovery if appropriate.
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Explain to the beneficiary, recipient or representative payee that because they recognize the signature on the check, the nonreceipt claim is invalid, and we cannot submit the claim to Treasury for processing.

For additional information, see SM 00609.105 How to determine if a nonreceipt claim is valid.

2. nonreceipt of a check issued 12 months ago or less

Treasury generates a claims package containing the FS-3858, FS-1133, and check photocopy when the check in question is 12 months old or less. The claims package is available on TCIS for printing until Treasury receives a completed package from the beneficiary, recipient, or representative payee.

If the claimant returns the form to the Field Office (FO) review the form for completeness carefully checking responses to questions 1through 6. Ensure the claimant signs and dates both sides of the form. Treasury uses this form as the basis to conduct a forgery determination. Treasury reclaims money from the bank if the signature indicates that the beneficiary, recipient, or representative payee may not have written the signature.

NOTE: Treasury will not process a photocopy of an FS-1133 for a nonreceipt claim. For Limited payability cases, see GN 02401.905.

C. Manual follow up on physical checks

If the check is still outstanding, the technician should input a nonreceipt action to have Treasury issue a courtesy disbursement check, if the check is less than 12 months old. If the 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. The technician must exhaust all efforts to locate the credit for the physical check. This includes examination of all queries and documents in the processing centers or field offices. Additionally, access the Treasury Check Information System (TCIS) to obtain the necessary information concerning the credit. Treasury reclaims the money from the death of the 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. A TCIS or Treasury contact will provide you with status and credit information. Use the information to post the credit via the SSA-4208 (Limited Payability Determination). Take the following actions:

IF	THEN
Treasury does not provide a document number for the SSA-4208...	Input all sevens (7) in this field.
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.
The investigation is old...	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 time frame.
If a physical, document is required (such as a photocopy of check)...	Call Treasury and request that they mail the document directly to you. 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. 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.

D. Nonreceipts alleged prior to death of claimant

Take the following actions for nonreceipt allegations prior to the death of a claimant.

IF	THEN
Completion of an FS-1133 is necessary in a nonreceipt claim but the payee is now deceased...	Have the form completed by an individual eligible to receive an underpayment. For more information on underpayments see GN 02301.030 and SI 02101.003 SSI Underpayment Due Individual Deceased-General.
No individual is eligible to receive an underpayment, and we need a forgery determination,...	Write "N/A" in the blanks for questions 1-8 on the FS-1133 and sign your name and position title on the bottom of the FS-1133. Obtain signature samples from the date of the check, such as gasoline receipts, cancelled personal checks, tax returns, and attach them to the FS-1133 with a note explaining why the payee (deceased) does not sign the FS-1133. Send to the address in GN 02406.160H in this section.

THEN

Completion of an FS-1133 is necessary in a nonreceipt claim but the payee is now deceased...

Have the form completed by an individual eligible to receive an underpayment. For more information on underpayments see GN 02301.030 and SI 02101.003 SSI Underpayment Due Individual Deceased-General.

No individual is eligible to receive an underpayment, and we need a forgery determination,...

Write "N/A" in the blanks for questions 1-8 on the FS-1133 and sign your name and position title on the bottom of the FS-1133.

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

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

E. Limited payability criteria

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

1.

Follow the procedures outlined in Handwriting Analysis Needed on a Limited Payability Case GN 02401.910.
2.

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

F. Treasury request for additional signature samples

Occasionally, Treasury requires additional signature samples when deciding on a case . These circumstances might include:

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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.
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Claimant who filed nonreceipt is now deceased and unable to complete an FS-1133 (Although the FS-1133 can be completed by a family member, signature samples 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. Additionally, ask for copies of cancelled checks or other examples of the claimant's signature from the pertinent time period. Call Treasury's general number (855-868-0151) and explain when a problem occurs. If necessary, TCIS can provide check images.

G. Claims Disposition Notice (CDN)

The CDN is a computer-generated form and does not have a form number. Based on the information on the FS-1133, the CDN provides the results of a forgery determination. The CDN may also indicate if Treasury needs more information for the forgery determination (e.g. additional signature samples from around the time the check was issued). Additionally, the CDN shows 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 the CDN to determine necessary actions. See the below chart for guidance.

IF	THEN
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.
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.

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NOTE: Treasury sends a CDN to the beneficiary, recipient, or representative payee.

H. Procedure for mailing completed forms

When a beneficiary, recipient, or payee comes into the field office for assistance with completing the FS-1133, take the following actions

STEP	ACTION
1	After providing assistance, instruct the beneficiary, recipient, or payee to mail the original FS-1133 to Treasury at the address provided. Do not mail to the PC or CO.
2	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 51318 Philadelphia, PA 19115.
3	Diary for 90 days for return of the CDN from Treasury
4	Obtain status of the case through TCIS or call Treasury at 855-868-0151.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0202406160

GN 02406.160 - Description and When to Use Department of the Treasury Forms FS-1133 and FS-3858 - 10/25/2024
Batch run: 01/27/2025
Rev:10/25/2024

Social Security

Program Operations Manual System (POMS)