915 Appendix C

The Department uses the Receipt of Payment (PA/CS 175-M) to ensure security, accuracy, and accountability when accepting and processing payments and checks for redeposit accepted at the CAO. The PA/CS 175-M provides a receipt for the person making the payment or returning the check for redeposit, as well as a tear-off stub receipt for each staff person involved in transferring the payment or check for redeposit.

The PA/CS 175-M is a controlled document. It contains specific data elements for payment tracking, posting, and audit purposes. No one may make corrections to the PA/CS 175-M. Anyone who completes a PA/CS 175-M incorrectly must void the original form and complete a new one. See Appendix H, Section IV, “Handling an Inaccurate PA/CS 175-M.” The CAO Issuing Officer is responsible for voiding and logging all PA/CS 175-M forms.

The CAO must complete two PA/CS 175-M forms if an individual makes a payment and returns a check for redeposit at the same time. If an individual makes a payment on claims involving different programs (such as reimbursement and restitution), only one PA/CS 175-M is required.

The Department and the OSIG will complete and process the PA/CS 175-M as follows:

I. Checks for Redeposit to Treasury, -DHS, BFO, or OSIG

A Departmental check may be issued by Treasury, the CAO, DHS-BFO, or OSIG. The DHS-BFO issues checks from its advancement account to refund excess child support collections. The OSIG issues a check from its advancement account to refund excess UC and SSI collections. The memo section of the check states the type of refund. Use the following procedures for checks that are unendorsed by the individual and are intended for redeposit.

A. Treasury or CAO issued check to be returned to Treasury

*Individual*/Payor	1. Brings treasury or CAO issued check to CAO for return.
CAO Receptionist	2. Refers *individual*/payor to the appropriate CAO staff person designated by the Executive Director.
CAO Representative	3. Obtains PA/CS 175-M from CAO Issuing Clerk.
CAO Issuing Clerk	4. Issue PA/CS 175-M in accordance with controlled document procedures in Chapter 810, Controlled Documents.
CAO Representative	5. Accepts treasury or CAO issued check from *individual*/payor.
	6. Completes PA/CS 175-M and signs page 1 only.
	7. Obtains *individual*/payor signature on PA/CS 175-M.
	8. Disburses PA/CS 175-M as follows:
	a. Gives page 1 to *individual*/payor.
	b. Forwards pages 2A, 2B, 3A, 3B, and returned check to CAO Issuing Clerk.
CAO Issuing Clerk	9. Completes PW 419 (Issuing Officer’s Controlled Document Log), filling in case name and record number.
	10. Forwards pages 2A and 2B to appropriate CAO Income Maintenance Caseworker (IMCW).
	11. Writes “void” on pages 3A and 3B.
	12. Forwards pages 3A and 3B to CAO Issuing Officer.
	13. Forwards check to designated CAO staff person responsible for handling returned treasury or CAO issued check.
CAO Issuing Officer	14. Places pages 3A and 3B in CAO PA/CS 175-M audit file.
	15. Retains above pages of PA/CS 175-M for three years from date of origin or until the audit is completed, whichever occurs first.
	16. Reconciles PW 419 with CAO Issuing Clerk at the close of each business day.
Designated CAO Staff Person	17. Processes treasury or CAO issued check in accordance with Chapter 810, Controlled Documents.
CAO IMCW	18. Files pages 2A and 2B in *individual* case record file.
CAO IMCW	19. Retains pages 2A and 2B for three years from date of origin or until the audit is completed, whichever occurs first.

B. Advancement account check to be returned to DHS-BFO or OSIG

*Individual* /Payor	1. Brings advancement account check to CAO to return.
CAO Receptionist	2. Refers *individual*/payor to the appropriate CAO staff person designated by the Executive Director.
CAO Representative	3. Obtains PA/CS 175-M from CAO Issuing Clerk.
CAO Issuing Clerk	4. Lists serial number of PA/CS 175-M; dates and initials PW 419 log.
CAO Representative	5. Requests the management or supervisory staff person designated by the Executive Director to assist in the receipt process and to attend the meeting with the *individual*/payor.
	6. Accepts check from *individual*/payor and writes “void” across the face of the check.
	7. Completes page 1, lines 1-5. In comments section, enters “Returned check – redeposit in DHS-BFO or OSIG advancement account,” whichever statement applies. Also enters reason for return, e.g. wrong account, issued to wrong person, doesn’t want check, etc. Signs in appropriate block.
	8. Completes only the name and county/record information on page 2B and signs in appropriate block.
	9. Obtains *individual*/payor signature.
	10. Obtains signature of management/supervisory staff person as CAO witness.
	11. Disburses PA/CS 175-M as follows:
	a. Gives page 1 to *individual*/payor.
	b. Forwards page 2B to CAO Issuing Officer.
	c. Mails pages 2A, 3A and 3B with check within two workdays to the following: child support advancement account checks to: Dept. of Human Services, Bureau of Financial Operations, Reimbursement Operations Section, P.O. Box 8196, Harrisburg, PA 17105-8196 and OSIG Advancement Account checks to: OSIG, Claim Accounting Section, P.O. Box 8016, Harrisburg, PA 17105-8016.
CAO Issuing Clerk	12. Reconciles PW 419 log with CAO Issuing Officer at the end of each business day.
CAO Issuing Officer	13. Files page 2B in CAO 30 working day PA/CS 175-M audit file.
DHS-BFO or OSIG	14. Receives returned check and pages 2A, 3A and 3B. Signs and dates pages 2A, 3A and 3B.
Advancement Account Section	15. Returns pages 2A and 3B to the CAO.
	16. Retains page 3A in receipt file for three years from date of origin or until the audit is completed, whichever occurs first.
	17. Processes check to advancement account.
CAO Representative	18. Ensures that 2A is filed in the case record file where it is retained for three years from date of origin or until the audit is completed, whichever occurs first.
CAO Issuing Officer	19. Matches page 3B with page 2B in CAO 30 working day control file.
	Note: If page 3B is not received from DHS-BFO or OSIG within 30 calendar days from date on page 2B or discrepancies appear on the form, immediately notify OSIG, Claim Accounting P.O. Box 8016, Harrisburg, PA 17105-8016. The memorandum will include a summary of the information contained on the PA/CS 175-M (names, dates, receipt number, etc.) that was submitted and the reason for the referral to OSIG. If the turnaround copy is received or the discrepancy is reconciled after the referral is made to OSIG, notify immediately by memorandum.
	20. Files pages 2B and 3B in CAO audit file.
	21. Retains pages 2B and 3B for three years from date of origin or until the audit is completed, whichever occurs first.

II. Payments on a Claim

An endorsed departmental check, personal check, money order, or cash mailed to the CAO can be accepted as payment on a claim. If the payment is in the form of an assistance check, examine the void date. Do not accept any check that will become void within 15 calendar days from the date you accept it as a payment.

A. Payments made at the CAO

*Individual* /Payor	1. Brings payment to CAO.
CAO Receptionist	2. Refers *individual*/payor to appropriate CAO staff person designated by the Executive Director.
CAO Representative	3. Accepts payment made by check or money order. Instructs *individual* who pays by cash to purchase a money order or make payment by check.
	4. Requests the management or supervisory staff person designated by the Executive Director to assist in the payment receipt process and to attend the meeting with the *individual*/payor.
	5. Obtains PA/CS 175-M from CAO Issuing Clerk.
CAO Issuing Clerk	6. Lists serial number of PA/CS 175-M, dates and initials PW 419 log.
CAO Representative	7. Accepts payment from *individual*/payor.
	Note: If a departmental check is accepted as payment, obtain *individual’s* endorsement on the check, and have check made payable to: Commonwealth of Pennsylvania.
	8. Completes pages 1 and 2B and signs in appropriate blocks on pages 1 and 2B.
	Note: If the *individual* or vendor returns all or a portion of a special allowance or child care allowance, enter in the comments section the reason for the return and list the program status code and reason code.
	9. Obtains *individual’s* signature.
	10. Obtains signature of management/supervisory staff person as CAO witness.
	11. Disburses PA/CS 175-M as follows:
	a. Gives page 1 to *individual*/payor.
	b. Forwards page 2B to CAO Issuing Officer.
	c. Mails pages 2A, 3A, 3B, and payment within two workdays to the following: Child support payments to: Bureau of Child Support Enforcement, Division of Field Operations, P.O. Box 8018, Harrisburg, PA 17105 Restitution, reimbursement, and unused special allowance payments to: OSIG, Claim Accounting Section, P.O. Box 8032, Harrisburg, PA 17105-8016.
	Reminder: The CAO will only mail payments made by check or money order to the Bureau of Financial Operations or to the OSIG.
CAO Issuing Clerk	12. Reconciles PW 419 log with CAO Issuing Officer at the end of each business day.
CAO Issuing Officer	13. Files page 2B in CAO 30 working day PA/CS 175-M audit file.
DHS-BFO or OSIG	14. Receives payment and pages 2A, 3A and 3B. Signs and dates pages 2A, 3A and 3B.
Headquarters Cashier	15. Returns pages 2A and 3B to the CAO.
	16. Retains page 3A in receipt file for three years from date of origin or until the audit is completed, whichever occurs first.
	17. Processes payment according to normal procedures.
CAO Representative	18. Ensures that 2A is filed in the case record file where it is retained for three years from date of origin or until the audit is completed, whichever occurs first.
CAO Issuing Officer	19. Matches page 3B with page 2B in CAO 30 working day control file.
	Note: If page 3B is not received from DHS-BFO or OSIG within 30 calendar days from date on page 2B or discrepancies appear on the form, immediately notify the OSIG Claim Accounting P.O. Box 8016, Harrisburg, PA 17105-8016. The memorandum will include a summary of the information contained on the PA/CS 175-M (names, dates, receipt number, amount, etc.) that was submitted and the reason for the referral to OSIG. If the turnaround copy is received or the discrepancy is reconciled after the referral is made to OSIG, notify immediately by memorandum.
	20. Files pages 2B and 3B in CAO audit file.
	21. Retains pages 2B and 3B for three years from date of origin or until the audit is completed, whichever occurs first.

B. Payments mailed to the CAO

CAO Staff	1. Receives payment and date stamps envelope.
CAO Staff	2. Forwards payment to CAO representative designated by Executive Director.
CAO Representative	3. Obtains PA/CS 175-M from CAO Issuing Clerk.
CAO Issuing Clerk	4. Lists serial number of PA/CS 175-M, dates, and initials PW 419 log.
CAO Representative	5. Takes PA/CS 175-M to CAO Issuing Officer.
	6. Verifies payment amount.
	Note: If payment is in the form of a check or money order, ensures the check is not stale-dated (within 15 days of void date). If the check is stale-dated, request the payor obtain a new check or money order immediately.
	7. Converts a cash payment to a money order, paying for the cost out-of-pocket. Submits a General Invoice (STD 152) to obtain reimbursement of out-of-pocket expenses.
	8. Checks box marked “mail” in the upper-left corner of the PA/CS 175-M. Checks “cash” if payment is made by this method. Enters “payment converted to money order” in comments section.
	9. Completes pages 1 and 2B and signs in appropriate blocks on pages 1 and 2B.
	Note: If the *individual* or vendor returns all or a portion of a special allowance or child care allowance, enter in the comments section the reason for the return and list the program status code and reason code.
	10. Gives PA/CS 175-M to CAO Issuing Officer.
CAO Issuing Officer	11. Signs PA/CS 175-M as the CAO witness on page 1 to validate payment amount received.
CAO Issuing Officer	12. Returns PA/CS 175-M to CAO Representative.
CAO Representative	13. Disburses PA/CS 175-M as follows:
	a. Mails page 1 to the *individual*.
	b. Forwards page 2B to CAO Issuing Officer.
	c. Mails pages 2A, 3A, 3B, and payment within two workdays to the following: Child support payments to: Bureau of Child Support Enforcement, Division of Field Operations, P.O. Box 8018, Harrisburg, PA 17105 Restitution, reimbursement, and unused special allowance payments to: OSIG, Claim Accounting Section, P.O. Box 8032, Harrisburg, PA 17105-8016.
	Reminder: A payment made by cash must be converted to a money order before it is mailed to the Bureau of Financial Operations or to the OSIG.
CAO Issuing Clerk	14. Reconciles PW 419 log with CAO Issuing Officer at the end of each business day.
CAO Issuing Officer	15. Files page 2B in CAO 30 working day PA/CS 175-M audit file.
DHS-BFO or OSIG	16. Receives payment and pages 2A, 3A and 3B. Signs and dates pages 2A, 3A and 3B.
Headquarters Cashier	17. Returns pages 2A and 3B to the CAO.
	18. Retains page 3A in receipt file for three years from date of origin or until the audit is completed, whichever occurs first.
	19. Processes payment according to normal procedures.
CAO Representative	20. Ensures that 2A is filed in the case record file where it is retained for three years from date of origin or until the audit is completed.
CAO Issuing Officer	21. Matches page 2B with page 3B in 30 working day control file.
CAO Issuing Officer	Note: If page 3B is not received from DHS-BFO or OSIG within 30 calendar days from the date on page 2B or discrepancies exist on the form, immediately notify the OSIG, Claim Accounting, P.O. Box 8016, Harrisburg, PA 17105-8016. Include a summary of the information contained on the PA/CS 175-M (names, dates, receipt number, amount, etc.) that was submitted and the reason for the referral to OSIG. If the turnaround copy is received or the discrepancy is reconciled after the referral is made to OSIG, notify immediately by memorandum to provide an update.
CAO Issuing Officer	22. Files pages 2B and 3B in CAO audit file and retains for three years from date of origin or until the audit is completed, whichever occurs first.

III. Stale Dated Checks

CAO staff should not, at any time, accept a stale dated-check, including a support payment check, as payment on a claim. Stale-dated means that the void date has expired. Additionally, the CAO should not accept a “near stale-dated” check (any check whose date is within 15 days of the void date).

Stale-dated checks or near stale-dated checks accepted in error must be returned to the payor by the CAO staff person who accepted the stale or near stale-dated check.

1. Write “void” on all pages of the PA/CS 175-M completed to receipt the payment.

2. Write in the Comments Section of the PA/CS 175-M “Returned to (fill in the name and work site of the person who accepted the payment as noted on the PA/CS 175-M) on (write the date the PA/CS 175-M and attachment is returned to the person who accepted the payment).”

3. Complete a HS 361-S, Standard Transmittal, noting the amount of the check, the budget payment name, the county code and case record number, the date the payment was originally received, the reason for returning the check, and the serial number of the PA/CS 175-M used for receipt of the payment.

5. Retain page 3 of the HS 361-S and file it in the 30 working day control file. Forward pages 1 and 2 of the HS 361-S with attachments to the CAO.

6. Match page 1 of the HS 361-S, when received, with page 3 and file in the audit control file. Retain for three years from the date of origin or until an audit is completed, whichever occurs first.

1. Recover all pages (Sections A and B) of the PA/CS 175-M not attached to the PW 361-S and write “void” on these sections.

2. Contact the payor by telephone within two workdays of return of the check to arrange to obtain a valid replacement check and return of PA/CS 175-M copy. The original check should be returned to the payor. The payor should immediately write “void” on the check.

NOTE: If the telephone contact is not made, a written request is made to the payor asking him to revalidate the check and return it to the CAO in the same payment amount and to return the PA/CS 175-M. Suggested language to be used when requesting revalidation is as follows:

“The check submitted to the CAO is not valid because the check is or soon will be void. The check should not have been accepted as a payment.

By law, only you can have the check revalidated. We are requesting that you take the check to your bank and have a new check issued in the same account. Bring the new check and the receipt issued with the payment to this office. Another receipt will be issued for the new payment. "We regret the inconvenience you may have been caused but do appreciate your cooperation."

3. Note on page 1 of the HS 361-S the action taken to recover the replacement check.

4. Sign, date, and return page 1 of the HS 361-S to the person who originally forwarded the document.

5. Place page 2 of the HS 361-S in the 30-working day control file until the replacement check arrives or 30 days elapses.

6. Retain page 2 in audit file for three years from date of origin or until an audit is completed, whichever comes first.

IV. Handling an Inaccurate PA/CS 175-M

As a controlled document, a PA/CS 175-M may not be altered in any way. If an error is made in completing the form, the PA/CS 175-M must be voided and a new PA/CS 175-M completed. If a person handling the PA/CS 175-M discovers a discrepancy at any point in the process, the person who made the error on the PA/CS 175-M is responsible for issuing a new receipt. Examples of a discrepancy include total payment amount on PA/CS 175-M not matching amount of payment, wrong case record number, or wrong claim name.

Person Who Discovers Error	1. Reverses the process by returning the PA/CS 175-M and payment to the person who made the completion error.
Person Who Handled Payment	2. Writes “Returned to originator – Error,” dates his control copy of the PA/CS 175-M, and returns the form to the audit file.
Person Who Made the Error	3. Voids the inaccurate PA/CS 175-M.
	4. Contacts the *individual*/payor to request return of the inaccurate PA/CS 175-M.
	5. Voids receipt returned from *individual/payor and issues a new PA/CS 175-M. The new receipt will reference the voided receipt number in the comments section. Sends/gives individual* their copy. Processes PA/CS 175-M according to normal procedures.
	6. If *individual/payor does not return the PA/CS 175-M within 10 workdays, prepare a new PA/CS 175-M according to normal procedures. The comments section should list the voided receipt number and the fact the original was not returned by the individual*/payor.
	7. Retains the voided PA/CS 175-M in the audit file showing the receipt number for the new PA/CS 175-M in the comments section of the voided receipt.
Person Who Handled Payment	8. Files new PA/CS 175-M with voided PA/CS 175-M in the audit file.

V. Handling an Incomplete PA/CS 175-M

If a person handling the PA/CS 175-M discovers that the form is incomplete, the form and payment must be returned to the person who made the completion error. Examples of such an error include a missing case record number, payment amount, or signature.

VI. Instructions for completing the PA/CS 175-M

Print neatly and press down if using a blue or black ink pen or type when completing the PA/CS 175-M form.

MAIL	Check this block if the payment was received in the mail.
PAYMENT TYPE	Place a check mark(s) in the appropriate box(es) indicating the type(s) of payment- - cash, check, or money order. If an assistance check is used as payment on a claim and is endorsed to DHS, place a check mark in the box “check.”
RETURNED UNENDORSED DEPARTMENTAL CHECK	Place a check mark in this box if the form is being used to receipt a departmental check.
CLAIM NAME	Enter the complete name of the person responsible for the money owed beginning with last name, first name, and middle initial. (For child support, this is the plaintiff).
SOCIAL SECURITY NUMBER	Enter the claim name’s social security number.
CO/RECORD NUMBER	Enter the two-digit county identification number, followed by the seven-digit case record number, category, grant group (if applicable), and the single letter/number of the district office, if applicable.
ADDRESS	Enter the complete street address of the claim name, including the P.O. box and zip code (enter nine-digit number if known).
NAME OF PERSON MAKING PAYMENT	Enter the complete name of the person making the payment in the CAO, beginning with the last name, first name, and middle initial, if different from the claim name.
BUDGET NAME	Enter the complete budget name if different from the claim name beginning with the last name, the first name, and middle initial.
ADDRESS	Enter the complete street address of the person making the payment, including the P.O. box number and zip code (enter nine digit number if known).
TOTAL PAYMENT AMOUNT	Enter the total sum of money received.
UNENDORSED DEPARTMENTAL CHECK DATA	Write the check number and date of the check in the designated areas of this block.
Restitution	Enter the amount of the payment to be applied to the overpayment claim. Place a check mark in the block indicating to which assistance program (Cash, SNAP, SNAP employment and training special allowance, or Medical Assistance) the payment is to be applied. Check the block for special allowance when submitting an overpayment referral for a child-care overpayment.
Restitution	Note: This block does not apply to an unused special allowance returned to the CAO.
Reimbursement/Support Code	Enter the appropriate reimbursement or child support code from the back of page 3 of the PA/CS 175-M. A child support code is used only when the payment is for child support.
Date of OIG 173 S or Telephone Call	Enter the date the Reimbursement Referral (related to this claim) was sent to the OSIG or the date the CAO called the OSIG to report the receipt of personal property.
Child Support	Enter the amount of the payment to be applied as child support. Check the block indicating if the support payment is voluntary or court ordered.
Defendant Name	Enter the complete name of the person who is liable for support payments, beginning with the last name, first name, and middle name.
Support Payor No.	Enter the support payor number. This information is available in the Cash Assistance Handbook, Chapter 131, Appendix B-1 (BCSINQ Procedures).
Date of PA/CS 4D	Enter the date of the PA/CS 4D, IV-D Recovery Referral form, corresponding to the payment.
Signature	The *individual*/payor and CAO staff persons who handle the transaction must sign in the designated area upon completion of the transaction.
Signature	Note: Before the form is signed, the CAO staff person should make sure the *individual*/payor reads the Notice located directly below the client signature line.
Comments	Briefly explain in this section any circumstances or miscellaneous information which is pertinent to the payment or the outstanding claim. If a miscellaneous payment is received, provide specifics regarding the payment circumstances in this section. If an *individual* pays a SNAP over-issuance involving electronic SNAP benefits, enter the following: “EBT account debited for the above amount with individual's permission.” Attach a computer printout verifying the removal of the benefits. If an *individual*/payor is returning a DHS-BFO or OSIG advancement account check, enter: “Returned check – redeposit in DHS-BFO or OSIG advancement account,” whichever statement applies, and indicate the reason for the return.
Audit File Stub	Complete the following noted blocks. The requested information is the same as that noted on the top half of the form.
a. Claim Name	Enter the complete name of the person responsible for the money owed beginning with the last name, first name, and middle initial.
b. County Processing Payment	Enter the name of your county
c. Co/Record Number	Enter the two-digit county number followed by the seven-digit record number, category, grant group (if applicable) and the single letter/digit of the district (if applicable).
d. Total Payment Amount	Enter the total sum of money received.
e. Payment Type	Place a check mark in the block which accurately indicates the method of payment - - cash, check, and money order.
f. Signature	The person who forwards the PA/CS 175-M with the payment to the next step in the process must sign this section of the form.
g. Date	The date the payment and receipt are forwarded to the next step in the process.

Person Who Discovers the Error	1. Reverses the process by returning the PA/CS 175-M and payment to the person who made the completion error.
Person(s) Who Handled the Payment	2. Writes “Returned to originator – Incomplete,” dates his control copy of the PA/CS 175-M and returns the form to the audit file.
Person Who Made the Error	3. Completes the missing section(s) of the PA/CS 175-M and notes the date the form was reprocessed in the comments section. Processes the PA/CS 175-M and the payment according to normal procedures.
Person Who Handles the Payment	4. Notes on the control copy the date the PA/CS 175-M was reprocessed and files in the audit file.

Appendix C: Receipting and Processing Payments/Checks for Redeposit – PA/CS 175-M