SSA-8508--Current Version

Form Approved
OMS No. 0960-0133

SUPPLEMENTAL SECURITY INCOME - QUALITY REVIEW CASE ANALYSIS

--==--__

1. SSN

0

2. Type of Review:
APOB/SO

---==-

ES SSN
Stewardship
State of Residence

0

_

SM

Other
SSA-FO Code

SSR DOCUMENTATION

FIELD REVIEW DOCUMENTATION

1. Interview date:

1. Name of Sampled Individual:

_

2. Sl's Existence Verified By:
2.

Residence Address:

o Direct Observation
o Other, Explain

_

Mailing Address: - - - - - - - - - - - - ­

3. Mis Listed Contacted:
3. Telephone:

_

0

4. Material Individual(s):

o Payee
o Ineligible Spouse
o Eligible Spouse
o Parent(s)
o Spouse of Parent
o Ineligible Child

DYes
No, Explain

o

None

4. AddresslTelephone Entries Correct on

o Alien Sponsor/Spouse
o Essential Person

~SR:

DYes
0 No, Correct:
Residence Address:

_

Mailing Address:

_

Telephone:

_

5. Others Contacted:
5. Name(s) of Ml(s):

-------------

6. Address: Same as Sl

0

Yes

o

o legal Guardian
o Institutional Officer
o Interpreter/Assistant

No

6. Federal Budget Month:

7. Federal Budget Month:

_

_

7. State Budget Month:

_

8. State Budget Month
8. 0
9.Last effective RZ or LI date:

_

CFR not requested
as the only deficiency is recipient caused
and information obtained during the review
clearly shows deficiency occurred after last
official contact and no pertinent data could
be obtained by reviewing the casefile.

9.Case Excluded: Code
Reason for exclusion:

Form SSA-8508 BK (06-2006)

EF (06-2006)

----------

Page 1 of 26

SSR-SYSTEMS

SI/MI INTERVIEW

1. SSN

D

Allegation/evidence agrees with SSR

SI

D

Different or additional SSN/names found

ES
Evidence viewed:
SS card
D Medicare card
Photo Ident.
Other
File includes POMS development required when SSN not issued prior to age 12.

o

D
D
D

Verified:

2. AGE
CITIZENSHIP/
LEGAL ALIEN
STATUS/IDENTITY

SI

ES

Name on Record

Date of Birth

Date of Birth
Birthplace

SI:

Parents
ES:
Type Evidence
Issuing Agency
Date Recorded
BIC
Date/Place Issued
Sl:
Alien Status
U.S. Entry Date

ES:

Port of Entry
Country of Origin
Alien Reg. #/
Class Code

AR CODE
SI:

Card Exp. Date
ES:

Form SSA-8508 BK (06-2006)

EF (06-2006)

Page 2 of 26

VERIFICATION

D SSN

CONCLUSION

D No SSN

verified via SS card/Medicare card

discrepancy

D

D Multiple

SSN verified via systems query (in-file).
Issue date

D File

SSNs
found but pay­
ment not
affected

includes POMS development required when SSN not issued prior to age 12.

D SI/ES
receiving SSI
under incorrect
or multiple SSN
See:

D

Allegation accepted. Age is not material.

D

Age verified via numident (ION code of P is indicated)

D

No material
age discrepancy

D Citizenship/

o

Age verified via Title II claim.
MBR proof of age code

o Age Verified - Other

_

Legal Alien
Status require­
ment met:

_

D
D

Allegation of citizenship by U.S. birth accepted.

D

Citizenship Verified.

U.S. born

D Naturalized
D Alien

_

D Refugee
D Collateral

Type/date:
Place:

D Other

contact made:
_

----------------------------

Name/title:

_

Finding:

_

Form SSA-8508 BK (06-2006)

EF (06-2006)

D Material
discrepancy
found

_

SSR-SYSTEMS

SI/MI INTERVIEW

3. MARITAL STATUS
CODE:
_

Marital History: (including parents of minor child)

Name

0

No

0

Event

Date

1.

Spouse Shown:
SI:

SSN

Yes
2.

Name:

Parents Shown:

3.
SI:

0

Name:

No

0

Yes
_
Evidence Viewed:
Type:

_

Names

Event date:

_

Issue Date:

_

Issuing Agency:,

_

Contributions from current or prior spouse:

Entitlement for benefits from spouse/former spouse:

SI lives with unrelated member of the opposite sex:
Name:
Alleged relationship:

Form SSA·8508 BK (06-2006)

EF (06-20061

_

Page 4 of 26

VERIFICATION

CONCLUSION

o Allegation agrees with SSR - no reason to doubt.
During review
period SI had:

o

o

Documentary evidence viewed.

o

o Collateral co~tact made:
_

Type/date:

Name/title:

_

Finding:

_

spouse

o
o

o

Holding out:

D
D

o

Established
Not established

D

OSee SSA-795s/4178s in file

o

See other evidence:

D

Potential Title II entitlement established:

_

Name:

Eligible
spouse

o Ineligible

_

Place:

No living
with spouse

No living
with parents

Eligible
parentIs)

Ineligible
parentIs)

Material
discrepancy
found:

_

SSN:
Type:

Form SSA-8508 BK (06-2006)

EF 106-2006)

Page 5 of 26

SSR-SYSTEMS

SI/MI INTERVIEW

4. LA/ISM
(Non Household)

CG

_

Facility (Name/Location)

_

Facility Representative (Name/Title)

Type of Contact/Date
FEDERAL LA
CODES

Did SI actively participate in interviews?
DYes

STATE LA CODES

STATE/COUNTY

_

o No

Date of admission to review period facility
Date of release from review period facility

_
_

Last date SI/ES was out of U.S.

_

I\lumber of residences over last 3 years

_

INSTITUTIONAL

Facility

Precedent:

o No

DYes

0

Public

0

Private - profit

0

Private - nonprofit

0

Penal

0

Medical care

0

Nonmedical care

0

Publicly operated
community residence

0

Public emergency
shelter

NONINSTITUTIONAL CARE

o Adult foster care
o Child foster care
o Other

_

Absence/Multiple Residences:

Form SSA-8508 BK (06-2006)

From

To

From

To

From

To

EF (06-2006)

Page 6 of 26

VERIFICATION

CONCLUSION

SI interview/contact with facility representative established the following:
_
_
_

D SI was institutionalized (date)
Size/number of residents
Total monthly cost
Amount of pmt for room/board
D Medicaid

D INSTITUTIONAL CARE
D Public medical
D Private medical

_

D SI's own income.

Amount

_

D Tax-exempt organization (Church-Key Amendment applies)
D Other third party:
Source
Amount

_

Substantial Medicaid?
DYes
D No
D Public or private
educational/
vocational/technical
D Publicly operated
community residence
D Private nonprofit
residential care

Payment excluded:

DYes

DNo
D Proprietary for
profit residential
care, educational,
or vocational
training facility

D SI was in noninstitutional care (date)
Placement by
Supervised by
License number and expiration date

_
_
_

D Public emergency
shelter
D Public correctional/
holding facility

D NONINSTITUTIONAL
CARE
Total cost:

D State living
arrangement:

Amount of pymt for room and board

Source of payment:
D S/'s own income.

Amount

D Foster care agency.

Amount

D ISM

U.S./State residency
requirement:

D Other third party

D Met

Source
Amount

LA/ISM deficiency:
DYes D No

D Other Contact Made
Type/date
Name/title
Place
Finding

Form SSA-8508 BK (06-2006)

D Not Met

_
_
_
_

EF (06-2006)

Page 7 of 26

SSR-SYSTEMS

SIIMI INTERVIEW

5. LA/ISM
(Household/
Transient)

Household Members
Relationship
to SI

Name
Pertinent CG
Entries:

Age

PA Income
Type

o LAO
(Sharing $

o LA 20 (Rent)
o LA 22 (PA)
o LA 23 (VTR)
o LA 24 (Room)
o LA - - - - o Other - - Federal LA Codes

State LA Codes

Sl living alone

SI (or living with spouse) has home ownership interest/rental liability

Mortgage amount $
Rent Amt. $ _ _-:-::...,...,----:-_

Sl lives in a residence owned or rented by a non-resident of Sl's household

Person in Sl's household with rental liability, if any
Amount:
_

Landlord/rental agency name, address, telephone number

_

State/County Codes
Landlord related to any household member?
_ _ Yes
No
If so, how/to whom?
J/H Income

If SI/ES does not have ownership interest or rental liability:
SI is a transient

SI is a child living in parent's HH

Sl is in an all-assistance HH

SI purchases/consumes food separately

Amount of shelter contribution. if any:
_
SI contributes toward total HH expenses in a sharing arrangement:
Amount $
_
SI earmarks contribution toward food and/or shelter expenses:
Amount (food) $
Amount (shelter) $
_

Sl lives with others and makes no contribution toward HH expenses

.,------------­

Services required by owner

Form SSA-8508 BK (06-2006)

EF (06-2006)

_

SIIMI HOUSEHOLD INTERVIEWS

Average Household Expenses
TYPE

AMOUNT

Food

$

Rent

$

Property Tax

$

Mortgage (include
property insur.)

$

Heating/Fuel

DESCRIPTION OF EVIDENCE

$

Gas

$

Electricity

$

Water

$

Sewer

$

Garbage removal

$

TOTAL

$

Above averages are for

D

Household member(s) not contacted because,

_

If SI or living with spouse has ownership interest or rental liability, amount of contribution(s) from other household
member(s), if any: $
_
Amount of food/shelter contributions from outside HH:

Housing subsidy
D No
DYes
Amount of subsidy (if known): $

D

$

_

Unknown
_

Length of time at review period residence

_

Number of residences during last 3 years
Last date SI/ES was out of U.S.
Amount of cash contributions and loans of ISM $
(see SSA-795 in file)

_

Temporary absence by SI or any household member:

Form SSA-8508 BK (06-20061

EF (06-2006)

Page 9 of 26

SI/MI HOUSEHOLD INTERVIEWS

Changes in living arrangements including household composition/expenses in review period:

Changes in household composition in review period

D

None

Changes in household expenses in review period

D

None

Changes in LA in review period

D

None

Form SSA-8508 BK 106-2006)

EF (06-2006)

Page 10 of 26

VERIFICATION

D LA/ISM/Residency
D

CONCLUSION

established during interview with SI/other household members.

Collateral sources contacted:
(Name, date, type of contact, findings)
LA/ISM Established

AVERAGE HOUSEHOLD EXPENSES
Amount

Description
of Evidence

Type
Food
Mortgage/Rent
Property Tax
Property Ins.
Heating/Fuel
Gas
Electricity
Water
Sewer
Garbage Removal
TOTAL

$
$
$
$

$
$

$
$
$
$
$

Basis for Federal LA

D

Home ownership:
Title
Life estate
Unprobated estate
Trust

D

Rental Liability
$
Rent
CMRV $
Flat Fee $
Room rental
Commercial
establishment
Non-commercial
Rent-free

D

PA household

D Separate

consump­

tion

D Separate

purchase

Above averages are for

D Sharing
D Earmarked

Number of household members:

$

Total household expenses
$

51's pro rata share
51's contribution

Other household member's contribution

Inside ISM (including VTR)

Outside ISM

sharing
food/shelter

D Transient
D Intervening
D

VTR applies

D

Child who ives in
household with
parent and who is
not subject to VTR

LA/ISM FOR:
CM

LA

ISM $

1M

LA

ISM $

BM

LA

ISM $

A

Basis for State LA
Inside ISM:
$
Outside ISM:
$

Last date SI/ES outside U.S.

U.S./State residency

Requirement:

Met D Not Met

D

LA/ISM Deficiency:
No
D Yes

D
Form SSA-8508 BK (06-2006)

EF 106-2006)

Page 11 of 26

SSR-SYSTEMS

SIIMI INTERVIEW

6. UNEARNED
INCOME

NOTE: Only 8M allegations need be shown if no income changes are alleged for review
period.

Title XVI
(CM)
SI:
CM

1M

8M
Retro

-----

MI:
CM

1M

BM
Retro

----Title II

SI:
CM

1M

8M
Retro

-----

MI:
CM

1M

BM
Retro

----Other

SI:

Sl's Allegations
(1M)
(BM)

Income Type

Title XVI
Title II
Interest
Bank Deposits
VA Pension
_ _ _ _ _ _ _ _ _ _ _ _ VA Compensation
Govmt. Pension
Private Pension
Railroad Retir.
Black Lung
Assistance Based
on Need
Educational
Assistance
State Disb. Pymt
Foster Care
Energy Assist.
Unemply. Compo
Worker's Compo
Sick Pay
Dividends/Royal.
Rental Income
Gifts
Loans
Support from
Absent Parent
_ _ _ _ _ _ _ _ _ _ _ _ Other Cash Supp.
Gambling Income
Miscellaneous

(CM)

Ml's Allegations
(1M)
(BM)

_

_

_

_

_
_

CM
EVIDENCE:

1M

BM
Retro

-----

MI:
CM

1M

BM
Retro

_

1099 ALERT
Title XVI Recoup

Form SSA-8508 BK (06-2006)

EF (06-2006)

Page 12 of 26

VERIFICATION

o Title XVI
OVA

o Title II
o

DOPM

CONCLUSION

o RRB

o

o Unearned income

Black Lung

did not cause an
error in the
sampled payment.

Verified by SSR - no reason to doubt

o Verified by award letter or other evidence in Sl's possession
o

D

Collateral contact made:
Type/Date

_

Place

The following
unearned income
amount caused a
payment error:
$-----­

Name/Title

_

Income/Income exclusion established

--'-

_

Type/Date

o
_

Type R/Type S
income received
by SI/ES in budget
month:

Place
Name/Title.

_

Income/Income exclusion established

_

o

o

Excluded court ordered support payments made by ineligible spouse/parent

D

Interest income, see Element B.

CM

D

1M

BM

_

Unearned income
exclusion applies
to SI/ES's budget
month income:

_

Ineligible child with unearned income:
Name/type:

CM

_

_ IM

_

BM

Verified by:

_

o Unstated income suspected/confirmed:

Form SSA-8508 BK (06-2006)

_

EF (06-2006)

o

Deeming applies

Page 130f26

SSR-SYSTEMS

7. WORK HISTORY
EARNED INCOME

SI/MI INTERVIEW

Last date of employment: SI
MI
Employment history for 3 yrs. ending with sample month:
Type of Work
Employer
Dates

Employee

Military:

Total quarters
from SER:
Year last
worked from
SER:

Review Period earnings:

1099 Alert:

Evidence:
SSR Wages:
SI:

Earned Income exclusions:
CM

1M
BM
Retro: Y_N
MI:
CM

o
o
o

Work expenses of BI
IRWE

o

Student child earned income

PASS

o None

Type

Amount

1M
BM
Retro: Y__ N

Frequency

Source

SEI:

Employment history prior to last 3 years:

Earned Income
Exclusions:

Form SSA·8508 BK (06-2006)

Union membership
-;­
Military service --,-------,_,........,....-:----:-_-:-:-----:-_----:-_ _-----::-:---::-:­
Pending claimlprior denial for benefits based on worklmilitary service

EF (06-2006)

_
_

Page 14 of 26

VERIFICATION

CONCLUSION

o Potential entitlement not suggested by SI/MI's allegations, no reason to doubt.
o Potential entitlement suggested:
o Title liN A - made referral to file
o Collateral contact below - made referral to file
o Ruled out by development in file
o Collateral contact made:

o No potential
entitlement to
other benefits

o Potential
entitlement
established for:

D No earned

Source:
Date/type:
Finding:

_
_

income in the
review period

_

D Review

period
earnings - no
payment error

o No earned income alleged, no reason to doubt.
o Earned income established:
D

See employer contact in file.

D The

D

See summary of SI/MI's records.

D

See SSA-795

following
earned income
caused payment
error: $

_

------

D No earned

D See

summary/copy of tax return.

D See

summary/copy of other business record in file.

income
exclusions apply

D Following

Gross wages:
CM

_

IM

_

earned income
exclusions apply:

BM

f\lE/SE amount/period

_

o Earned income exclusions established:
Type:
Amount/frequency:
Established by:

D Ineligible child

_
_
_

with earnings:

Name
Amount: CM

_
_ IM

BM

o Deeming applies

_

Verified by:

Form SSA·8508 BK (06-2006)

EF (06-2006)

Page 15 of 26

SSR-SYSTEMS
8. LIQUID
RESOURCES

Direct Deposit

BCR:
BCA:
Name

SIIMI INTERVIEW
Type of Resource

Allegations
SI

_

_

1099 Alert

CG Entries
D RE01
SV
CK
D RE04
D RE08
CD
D RE21
Svgs Bds
DRE,_ _

MI

Checking Account
Savings Account
CD
Other Bank Account
(Christmas club, etc.)
Prepaid Burial Plan
Patient Account
Savings Bonds
Promissory Notes
Stocks/Bonds
Mutual Funds
Credit Union
Safe Deposit
Miscellaneous
401 (K) Plans/Keough Accts.
Trusts
Cash on Hand: $
Life Insurance Dividend Accumulations

_

Positive Allegation Information:

--+
-+

Type:
Institution:
Owner(s):,
ID:
Date/Balance:,
Encumbrances:...:

t­

_

--+­

_

-+­

_

----1.

Is your name on anyone else's bank acct?
Deposits by joint owner: D No

_
_

D Ves

D

_

No

DVes

Amount of joint owner deposit(s) $
Dates made:,

_
_

D No accounts alleged
Check cashing location
mortgage, pers. loan from
Prior accounts last 24 months at
Place where funds are kept for burial
Other financial institutions used to transact business

Form SSA·8508 BK (06-2006)

EF (06-2006)

_
_
_

Page 16 of 26

VERIFICATION

o

CONCLUSION

SI has been in an institution/non institutional care facility for at least 3 years - no
reason to doubt negative allegation.

o

o Collateral contact made (Include patient account)
Type/date:

1. Address:
Finding:

_ Inst. Name:

_

Total countable
liquid resources
did not exceed
resource limit
during review
period

--------------------------

o

o Account type

No Account
Account 1o
Owner(s)
Balances
Interest

-------­
CM $ _ _ _ _ _ _

o No

,........,.-----------:-----­
1M $
BM $
_

0

Type/date:

o

_

Liquid resources
caused or con­
tributed to­
ineligibility for
the sampled pymt

Yes, see Element 6

Inst. Name:

_

2. Address:

_

Finding:

o No Account
Account 1o
Owner(s)
Balances
Interest

o Account type

_

---------:-:-::,.......,....---------:::-':'""':"'"-:------­
CM $ _ _ _ _ _ _ 1M $
BM $
_

o Yes, see Element 6

ONo
Type/date:

Total countable
liquid resources
on first day of
sample month:

SI

Inst. Name:

_

_

3. Address:

MI

Checking:_ _---+-__

_

Finding:

o No Account
Account 1o
Owner(s)
Balances
CM $ _ _ _ _ _ _
Interest
ONo
Type/date:
4. Address:
Finding:

_

_
-:-..,....1M $

---::-:-:-:BM $

_
_

_
_

o

EF (06-2006)

Other:

o Yes, see Element 6

Inst. Name:

No Account
Account 10
Owner(s)
Balances
CM $ _ _ _ _ _ _
Interest
ONo

Form SSA-8508 BK (06-2006)

Savings:

o Account type

o Account type
--:1M $

Total:

_
---:::-':'""':"'"--:BM $

_
_

o Yes, see Element 6

Page 17 of 26

SSR-SYSTEMS

SIIMI INTERVIEW

9. REAL PROPERTY
Allegation of real property ownership by SI/MI:

RE Field Entries

D None

Ownership interest:

D

D

SI is sole owner (non-life estate)

D

MI is sole owner (non-life estate)

D Non-farm

D

Jointly owned with spouse

D Farm

D Jointly owned

Home property
Type:

D Trailer/Mobile home D Jointly owned
D Other

D

D Other

CG Entries

D

D
D
D

D

D
D

estate

(equitable ownership, remainder interest, etc.)

Unknown

Nonhome property
Type

D
D
D
D

with non-relative

Life-estate

D Unprobated

D

with relative (non-spouse)

Owner

Value

Farmland (rented)
Farmland (used by SI/MI)
Commercial (non-farm) or residential property, rented
Commercial property (non-farm) used by SI or MI
Unexcluded previous or second residence (not rented)
Unimproved land, idle
Foreign property
Other (mineral, timber, water rights, easements, etc.),
Unknown (type cannot be determined)
Evidence of ownership/value

CMV:

_
_
_
_
_
_
_
_
_
_

_

D Encumbrances

_

D Burial

plot/crypt
Location/Number
Designated for:

_
_

D Transfer of property
To,-:
Reason:
Compensation:

D Attempt
D Income

Form SSA·8508 BK (06-2006)

EF (06-2006)

to dispose of property:

producing property:

Date:

_
_
_

_

_

Page 18 of 26

VERIFICATION
SI has been in an institutional/noninstitutional care facility at least 3 years - no
reason to doubt negative allegations.

Allegations verified by government records:

o

CONCLUSION

o
o

No real property
ownership
established for SI/MI
SI/MI owns
excluded home
property

Alpha listing

Contact method (e.g., personal visit, letter, phone)

Date of contact

Name of contac.....

t-----------------------­
Title of contact

o

SI/MI owns
nonexcluded real
property valued
at:
$----­

Finding:
No property ownership

o
o

Home ownership

o SI/MI owns

Nonhome (including burial plot) ownership

o Nonhome (including non-excluded burial plot) ownership

o

excluded other
property (ex.
burial plot)

Owner
Locatiortn--------------------------­

CMV
(duration of ownership interest)

Owner
Locatiortn--------------------------­

CMV
(duration of ownership interest)

Other collateral contact made:

o Type contact/date
Finding

Form SSA-8508 BK (06-2006)

EF (06-2006)

Page 19 of 26

SSR-SYSTEMS
10. VEHICLES

SIIMI INTERVIEW

o
o

None alleged
Positive allegation

1

2

3

RE Field Data
Yr/Make:
Model/Body:
Condition:
Owner:
Use:
VIN:
License #:
CG Entries

RE 1

o Transfer alleged
o
o Evidence viewed:
o Title
o Regist.
o Additional information to verify value/use/ownership
o Handicapped equipped
o Encumbrances

o Duration of ownership:
11. LIFE
INSURANCE

RE Field Data

CG Entries

Other

_

_

o None alleged
Positive
allegation

Insurance Co.

Policy Number

-------Owner

Insured

Face Value

Cash Value

Outstanding

Loan

Age at Issue

Issue Date

Prem. Amt./Frq

-------Type of Policy _-==-=---:-:------,.....,....--,-_
Policy Vwd
0 Policy Vwd
Inf. Allgd
0 Inf. Allgd
Particip.
0 Particip.
Fully paid insurance policy?
0 Yes
0 No

o

o
o

o Policy Vwd
o Inf. Allgd
o Particip.

If the policy is not paid up, what is the premium amount and frequency of payment?
Amount $

-------

Frequency

If yes, does supplemental contract exist?

_
DYes

o

No

Does the policy produce dividend additions or dividend accumulations?

DYes
0 No
0 Unknown

o Transfer alleged
o Accelerated life insurance payments
Form SSA-8508 BK (06-2006)

EF (06-2006)

Page 20 of 26

VERIFICATION

o No reason to doubt negative allegations.
o N.A.D.A. value(s):
o

CONCLUSION

o No vehicle owner­
ship by SI/MI
Encumbrances

o

Vehicle exclusion
applies:
Value under

limit.

Employment
Other

o
o
o

OSee SSA-795 regarding vehicle use.

Total vehicle value

$--------

o Collateral contact made

Nonexcluded value
Name

_

Type contact/date

$-------­
_

Finding:

o No reason to doubt negative allegations
o Collateral contact made
Company

o

Policy

No life insurance
ownshp by SI/MI

o Dividend accum.

Owner

value

o Face value does
CM

1M

not exceed $1 500
per insur. indiv.

BM

Total CSV is
SI
CM

Total face value:
Total CSV:

D

CSVIdividends set aside for burial (see SSA-4169/SSA-795 in file)

_
MI
_

1M
BM

_

Retro

_

o Face value
Dividends paid

o

No

o

exceeds
$1,500
per insured.

Yes (see Element 6)

Ownership

_

Pertinent values

_

Dividend accumulation values

_

D

Countable CSV
value of life ins
SI
MI
CM
_

1M
BM

'--

_

Retro

'----

_

o CSV dividends
set aside for burial

Form SSA-8508 BK (06-2006)

EF (06-2006)

SSR-SYSTEMS
12. RESOURCES
SUMMARYIOTHER
NON LIQUID
RESOURCES

13. REPRESENTATIVE
PAYEE
Repy:

SI/MI INTERVIEW

D

Transfer alleged

D

Income producing

D

Encumbrances

D

SI/MI alleges following resource(s) are to be used for burial expenses:

D

No alleged or observed need for payee development/change.

D

Payee development suggested by:

D

No fraud suspected

D

Fraud suspected before or during interview due to:

T:
CO:
CU:
Name:

_

14.FRAUD

Form SSA-8508 BK (06-2006)

EF (06-2006)

Page 22 of 26

VERIFICATION

D

No reason to doubt negative allegation

D

Collateral contacts made:
Name:

CONCLUSION
Total nonexcluded
resource values:
Liquid

_

SI

MI

CM
Type contact/date",-:

_

1M
8M
Retro

Finding:

...L..-

_

Nonliquid
SI
MI

CM
1M
8M
Retro

...L..-

D Deeming

D

Resources excluded due to burial designation, PASS, etc.:

D No payee development required

D

payee
development
required.

_
_

o No development required

DYes

D FO

to field office for payee development

Name,
Type contact/date
Finding: (explain above)

applies

Resources cause
ineligibility:

D No

D Referred

_

D No development
required.

D

No fraud
suspected

D

Fraud
referral made

Fraud referred due to:

Form SSA-8508 BK (06-2006)

EF (06-2006)

Page 23 of 26

SUPPLEMENTAL DOCUMENTATION
15. DEATH OF MI

DH:

Name

_

_
Relationship to SI

_

Date of death

_

Evidence viewed

16. STUDENT STATUS

STUDENT NAME
School Name
School Address
Dates of Attendance
Type of Course
Evidence Viewed
STUDENT NAME
School Name
School Address
Dates of Attendance.
Type of Course
Evidence Viewed

_
_
_
_
_
_
_
_
_
_
_
_

FULL TIME ATTENDANCE
17. AGE

o Eligible Children
(not SI)
o Ineligible Children

o CG
DM 0

Yes

o

No

Evidence presented by SI/MI, or derived from collateral contact
Name
Date of Birth
Place of Birth
Record Type, ID #.
Issuing Agency
Date of Issue.
Date Recorded
Mother's Name
Father's Name
SSN

_
_
_
_
_
_
_
_
_

Name
Date of Birth
Place of Birth
Record Type, ID #
Issuing Agency
Date of Issue.
Date Recorded
Mother's Name
Father's Name
SSN

18. RELATIONSHIP
Ineligible child of SI

o

_
_

_

_

_

o Parent to eligible child
o Spouse as parent to eligible child
o Alien sponsor to spouse/dependents
o Other
EF 106-2006)

_
_
_
_
_

,....-

o

o

o Ineligible sibling of SI

Form SSA-8508 BK (06-2006)

0

Birth record (see above/pg. 2)
Marriage record
Name'-­
Date
Issued by

_

Place

_
_
_

_
Page 24 of 26

VERIFICATION

o None required
o Collateral contact made

CONCLUSION

Payment effect $

o Pymt deficiency
o Nonpayment

Name
Contact type/date
Finding:
Evidence viewed:

deficiency

o None required
o Collateral contact made

o No discrepancy
o Material

Name

Contact type/date

Finding:

discrepancy

o Evidence viewed (see page 24)

0

None required

0

Numident in file

0

Collateral contact made
Name
Contact type/date
Finding:

0

Evidence viewed (see page 24)

ION

o No discrepancy
o Material
discrepancy

SSNs for children

0

Evidence viewed

0

Numident in file

0

Collateral contact made
Name
Contact type/date
Finding:

o No discrepancy
o Material
discrepancy

Form SSA-8508 BK 106-2006)

EF 106-2006)

REMARKS/DEFICIENCY ANALYSIS

9

_R_e_V_ie_w_er_._S_S_i__n_at_u_r_e

Form SSA-8508 BK (06-2006)

I_D_a_te

EF (06-2006)

_

Page 26 of 26