Centenarian Project Development Worksheets: Face-to-Face Interview and Telephone Interview

r.,m, Aprnoved
~CJUAI

\1 ( liRirY AIJMINIS I KA lltlN

OMO No 091>(1-0780

Centenarian Development Worksheet
Telephone Interview
Individual: •
Centenarian:
Advanced Telephone Call Date: •
Date letter sent: •
Flu letter sent: •
Individual Is Alive:
If the Centenarian
1. Date of Interview
2. Date of Birth Correct?
3. Address correct?
4. Payee needed?
5. Change of payee needed?
6. Special message posted·
7. ID questions(s) used to establish identity

Individual is Decea.s ed:
If the Centenarian
1 Date of Death (mm/ddtyyyy)·
2 Proof of Death type.
3 Proof of Death posted to EVID?
4 Date of Termination action.
5 Was a payee Involved?
6 Possible FRAUD Involved?
7 OIG referral?
If no OIG referral, explain 10 REMARKS
8 Estimated amount of overpayment:
9 Special Message posted:
10. REMARKS:

SSN: XXX·XX•

•
DYES
DYES

DYES
DYES
DYES

DNO
DNO
D NO
DNO

•

D YES
DYES
DYES
DYES
'$
DYES

(mandatory)

O NO
D NO
D NO

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
PRIVACY ACT STATEMENT
Collection and Use of Information
Centenarian Development Worksheet
Telephone Interview
Section 202(j) of the Social Security Act, as amended, authorizes us to collect this information.
We will use this information to determine your benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision regarding
your benefit eligibility.
We rarely use the information for any purpose other than for making a decision regarding benefit
eligibility or cessation. However, we may use it for the administration and integrity of our
programs. We may also disclose the information to another person or to another agency in
accordance with approved routine uses, which include, but are not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security
benefits and coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g.
to the Government Accountability Office and Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigatory activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
5. We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for federally-funded and administered benefit
programs and for repayment of payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice entitled, Claims Folders Systems, 60-0089. This notice, additional information
regarding our programs and systems are available on-line at www.socialsecurity.gov or at your
local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-0001.