Form H4100, Money Receipt

Effective Date: 1/1991


Word: H4100.doc

PDF: H4100.pdf


Updated: 9/2004


  • To serve as a standard, all inclusive procedure for receipting money.
  • To serve as a method of controlling money from the point it is received by the agency.
  • To serve as a reporting and transmittal document to Fiscal Management Services.
  • To serve as a tracking system for money receipts.
  • To serve as a reporting document to program managers.
  • To serve as a permanent record of money receipts.


When to Prepare

All money received by HHSC staff is receipted using Form H4100. “Money” includes cash, money orders, certified checks, cashier’s checks, state warrants, unused food stamps, and any other negotiable instruments. Payments received by department staff in person are receipted immediately. Payments received by mail are receipted as soon as the mail is opened. Receipts are issued for checks received without signatures, checks made payable to the incorrect payee, and all other payments received by the department.

Exception: CSS Recovery Units use an automated version of Form H4100 (Fiscal Transmittal Report) for payments forwarded to Fiscal Management Services.

The manner of processing depends upon the kind of payment received. For example, a donation to a county received by a child welfare unit is processed in accordance with the agreement with the county; a child support payment received on a court ordered case is processed in accordance with the court order; and a vending machine commission check is forwarded to Fiscal Management Services. State warrants (including TANF warrants, social services warrants, undelivered payroll warrants, undelivered travel warrants, and any other state warrant) are receipted and forwarded to Fiscal Management Services for processing. Returned food coupons should be receipted and voided prior to forwarding to Fiscal Management Services. In the absence of specific requirements, send payments to Fiscal Management Services.

All money receipted must be forwarded to Fiscal Management Services the same day of receipt.

How to Prepare

Prepare four copies of Form H4100. Use sufficient pressure to ensure that all copies are legible. Print all information using a ball point pen.


Original — The original receipt is given to the payor, or it may be mailed at the discretion of the appropriate regional administrator, the department director, or the program manager.

1st copy — The 1st copy is sent to Fiscal Management Services, along with the payment, if the payment has been identified as one that should be deposited directly into the state treasury.

2nd copy — Program copy (casefolder).

3rd copy — Do not remove. This copy must remain in the receipt book.

Payments Receipted but Not Forwarded to Fiscal Management Services

Non-Negotiable Payments

Any checks or money orders which are not negotiable should be returned to the payor with instructions to provide the necessary information on the payment document. For example, checks or money orders in which one or more of the following types of information was omitted or is incorrect:

  1. Signature of payor.
  2. The name of the payee.
  3. Missing amount.
  4. Conflicting longhand and numeric amounts.

When this occurs, check the 'Disposition/Other" box and enter an explanation in the space provided, such as "returned to payor — no signature." All copies of the receipt are routed as described in "Transmittal" above.

Note: When the payor resubmits the corrected payment, it is treated as a new item for receipt purposes.

Child Welfare Payments

Payments for child welfare may be forwarded to a local child welfare account in a private bank, or to the city or county treasury, via the child welfare board or Department staff member depending on local arrangements. When this occurs, check the “Disposition/Other” box and enter the bank account number or the name of the county treasury account in the space provided.

Payments with a Payee Other Than the Department

If the payee is someone other than the Department, such as the Texas Department of Health, the money should be forwarded, if appropriate, to the payee. If the payment is made out to an incorrect payee, it should be returned to the payor with instructions as to the correct payee. When this occurs, check the “Disposition /Other” box and enter an explanation in the space provided, such as “forwarded to Tex. Health Dept.” or “incorrect payee — returned to payor.”

Processing Incorrect Payments

If there is an error, such as a payment is for the incorrect amount, the payment is receipted and forwarded for deposit.

If for any reason a payment received cannot be processed in accordance with the prescribed procedure, the money must be receipted. The copy of the receipt sent to Fiscal Management Services must be accompanied by a memorandum signed by the person administratively responsible explaining in detail the circumstances and the disposition of the money. A copy of the memorandum must be sent to the Director, Audit Division, State Office. Include in the memorandum the name of the bank on which the check was written and the town where the bank is located.

Voided Receipts

When it is necessary to void a receipt, print “VOID” on the receipt and send the original and first two copies to Fiscal Management Services.

Form Retention

The first copy is microfilmed as part of the Fiscal Management System. Filmed copies are retained for audit purposes for five years. The second copy (program copy) is retained by the responsible program manager in accordance with the provisions outlined in appropriate program handbooks. The third copy remains in the receipt book. When all receipts in the book are completed, the book is kept in a safe place for audit purposes for three years. Minimum safeguards include storing the receipt books in a locked file cabinet.

Detailed Instructions

Date — Enter the date the payment was received.

Subject to collection, this is to acknowledge receipt of $ ________ — Enter the amount of the individual payment.

Subject to verification, this leaves a balance of $________ — Enter the remaining amount due, if applicable. If not applicable, enter "N/A".

Credit to the account of — Enter the name of the recipient/client against whose account the payment is to be credited if different from the payor. If same, enter "same." If the payment is not designated for a specific client, list the fund or account to be credited.

SSN or PIN — Enter the social security number or the payment identification number of the recipient or client against whose account the payment is to be credited.

Account No — Leave blank. This space is for state office Fiscal Management Services use only.

Next Payment Due — Enter the month/day/year the next payment is due, if applicable. If not applicable, enter "N/A."

Received From — Enter the name and address of the payor. (This section is positioned on the receipt to fit a window envelope.)

Disposition — Check the appropriate box. If the "Other" box is checked, give a brief explanation in the space provided, such as "returned to payor — no signature."

For — Enter a description of what the payment is for such as:

Financial Services

  • Food stamp overissuance restitution
  • TANF overpayment restitution
  • Medicaid restitution
  • Issuing agent payment for overissuance
  • Foster care refund
  • Financial services administrative expense refund
  • Damaged commodity income
  • Commodity assessment fee
  • Disaster relief grant
  • Cuban refugee grant
  • Indochinese grant
  • Repatriated citizen grant

Social Services

  • Reimbursements for TANF and State paid foster care
  • Payments for care and other expenditures for non-TANF Foster care children
  • Donation for clothing, toys, school supplies, and other miscellaneous items for children and families
  • Donation for emergency needs of clients (food, utilities, prescriptions)
  • Fees received from courts for completed social studies
  • Refund for overpayment to foster parents
  • Medical refund from hospital or doctor (refund to the Department after Medicaid paid for services)
  • Petty cash/reimbursement from bank account to pay expenses paid for by supervisors or caseworkers for foster children
  • Document reimbursement
  • Christmas donation and reimbursement
  • Reimbursement for transportation of child welfare child
  • Audit exception refund
  • Donor fund for social services contracts
  • Individual provider overpayment refund
  • JTPA training reimbursements
  • Social Services restitution refunds
  • Other social services receipts
  • Reimbursement for JOBS transportation expenses

Family Code

Family code — central records file fees

Medical Programs

  • Medicaid reserve collection
  • Other medical refund
  • Reimbursement from MHMR for patient in nursing facility
  • Medical programs' fund
  • Medical programs' restitution

License Fees

  • Child care administrator's license fee
  • Examination fee
  • Child care administrator's license renewal fee

Miscellaneous Cash Receipts

  • University contract monies
  • Vending machine income
  • Coin operated telephone income
  • Miscellaneous receipt from private source
  • Conscience money
  • Educational stipend repayment
  • Lost book payment
  • Sale of publication
  • Sale of waste paper
  • Unidentified check
  • Refund of administrative expense
  • Texas Youth Council — data processing service
  • Texas Commission for the Blind — reimbursement for copies
  • Governor’s Committee on Aging — data processing service
  • Reimbursement for supplies or equipment lost in shipment
  • Reimbursement — Texas Department of Community Affairs
  • Refund of Medicaid payment
  • Reimbursement for telephone expense from county

If a payment is received which is to be credited in-part to more than one account, only one receipt is required. Reference each pertinent account in the "For" section. Multiple entries may be necessary in the "Type of Case" and "Case No." boxes.

Type Case — If applicable, enter the program affected; for example, TANF, food stamp, Medicaid.

R/D — If applicable, enter the relevant region or division.

PAC — If known, enter the relevant program activity code. (The PAC should be completed by the Regional Budget Office for all receipts that are deposited into a local bank account.)

Case No — Enter the department case number(s) assigned to the case(s). If no specific case is designated, leave blank.

Add'l No. (Additional Number) — Enter any additional numbers associated with the payment (such as Office of Inspector General case number, requisition number, payment voucher number).

Type Payment — Enter the type of payment received, such as money order, cashier's check, personal check, or food coupons.

Check/M.O. No. — Enter the number of the check or money order.

Received By — The person designated as responsible for handling the receipts should sign the form.

BJN — Enter the responsible person's budgeted job number.

Note: The employee BJN must be completed to provide a list of payments received and processed in Fiscal Management Services.

Phone Number — Enter the responsible person's area code and phone number, or their STS number.

City/Mail Code — Enter the responsible person's city and mail code.

Note: Except for returned state warrants and food coupons, each negotiable instrument to be sent to Fiscal Management Services should be immediately endorsed "Pay to the Order of State Treasurer of Texas, for Deposit Only, HHSC." Return undelivered state warrants to Fiscal Management Services unendorsed. Mark food coupons "canceled." Send them to Fiscal Management Services without endorsement.

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