Form SSA-8508-BK Supplemental Security Income--Quality Review Case Analys

Form Approved
OMB No. 0960-0133

SUPPLEMENTAL SECURITY INCOME - QUALITY REVIEW CASE ANALYSIS
SSN:

State of Residence:

SM:
Title XVI Stewardship

ES SSN:

AIPQB:
SSA-FO code:

Case Excluded?
Exclusion code:

SSR DOCUMENTATION

Yes

No

FIELD REVIEW DOCUMENTATION

1. Name of Sampled Individual

1. Interview Date

2. Residence Address/Telephone number

2. SI’s Existence Verified by
Direct observation
Other

3. MI(s) listed contacted
Yes
No, Explain

3. Mailing Address

4. Address/Telephone entries correct on SSR
Yes No (provide correct address)
4. Material Individual(s)
Payee
Eligible spouse
Spouse of Parent
Alien Sponsor/spouse
5.

None
Ineligible Spouse
Parent(s)
Ineligible Child
Essential Person

Mailing Address

Name(s) of MI(s)

6. Address same as SI?

Residence Address/Telephone Number

Yes

No
5. Others Contacted:

7. Federal BM

Legal Guardian
Institutional Officer
Interpreter Assistant

6. Federal BM

7. State BM
8. State BM

9. Last Effective RZ/LI

Form

SSA-8508 BK (10/2008)

8. 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.

1

SYSTEMS

SI/MI INTERVIEW

1. SSN

Allegation/evidence agrees with SSR

SI:

Different or additional SSN/names found

ES:

Evidence viewed:
SSN card

Medicare card

Photo Identification

Verified:
Other

2. AGE
CITIZENSHIP/
LEGAL ALIEN
STATUS/IDENTITY

Allegation

SI

ES

Name on Record

Date of Birth
Date of Birth
SI:
Place of Birth
ES:
Parents Names

Mth:

Mth:

Fth:

Fth:

Type of Evidence
BIC
Issuing Agency

SI:

ate Recorded
ES:
Date/Place Issued

Alien Status
AR CODE
SI:

U.S. Entry Date

ES:

Port of Entry

Country of Origin

Alien Reg. # /
Class code
Card Expiration
Date

Form

SSA-8508 BK

(10/2008)

2

VERIFICATION

CONCLUSION

SSN verified via SSN card/Medicare card

No SSN
discrepancy

SSN verified via systems query (in file)

Multiple SSNs
found but
payment not
affected

Issue date

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

Allegation accepted. Age is not material.

Allegation of Age
Accepted

Age verified via numident (IDN code of P is indicated)
Age Verified
Age verified via Title II claim.
MBR proof of age
Does not meet age
requirement
Age Verified-other

Allegation of Citizenship by U.S. birth accepted
Citizenship/Alien status verified?
Type of verification

Yes

No

Citizenship/
Legal Alien
Status
requirement met
U.S. born
Naturalized

Collateral Contact Made
Type/date

Alien
Refugee

Place

Other
Name/Title
Does not meet
Citizenship/Alien
Status

Findings

Form

SSA-8508 BK

(10/2008)

3

SYSTEMS
3. MARITAL STATUS
CODE:

SI/MI INTERVIEW
Marital History: (including parents of minor child)
Spouse
or
Parents

Spouse Shown:
No

Yes

Name:

Parents Shown:

Name

None

SSN
if SSN is unknown,
provide
DOB/POB/mothers
maiden name

Spouse
No
Parents

Married
Divorce
Separated
Widowed

Spouse

Married
Divorce
Separated
Widowed

Parents
Spouse

No

Yes

Names:

Event

Parents
No
Spouse
Parents

Date

Married
Divorce
Separated
Widowed
Married
Divorce
Separated
Widowed

Evidence Viewed

Contributions from current or prior spouse? Yes No
If yes, indicate name of spouse and amount of contribution

Entitlement for benefits from spouse/former spouse? Yes
If yes, indicate Name and SSN, or DOB if SSN is unknown

No

Does SI live with an unrelated member of the opposite sex? Yes No
If yes, provide the following information
Name
Alleged Relationship

If Disabled, Date SI first became disabled
Note: This may not be the same date as that established on the SSR

Name SSN’s/ID info for parents either disabled, deceased or age 62 or over.
If SSN is unknown, provide DOB/POB/Mother’s Maiden name
Mother
Father

Form

SSA-8508 BK

(10/2008)

4

VERIFICATION

Allegation agrees with SSR - no reason to doubt.

CONCLUSION

During review
period SI had:

Documentary evidence viewed.

No living
with spouse

Collateral contact made:

Eligible
spouse

Type/Date
Ineligible
spouse

Place

No living
with parents

Name Title

Findings

Eligible
parent(s)

Holding out:

Established
Not established

Ineligible
parent(s)

See SSA-795s/4178s in file
Other evidence

Potential T2
Entitlement
Referral:
Potential Title II Entitlement established:
Name

Yes

No

SSN

Type

Form

SSA-8508 BK

(10/2008)

5

SYSTEMS

SI/MI INTERVIEW
NA

4. LA/ISM
(Non Household)

Facility Name/Address
Facility Representative
Name/Title
Type of Contact/Date

CG:

FEDERAL LA
CODES:

Date of Admissions to the review period facility

Did the SI actively participate in the interview?

Yes

STATE LA CODES:

Is the SI currently residing in the facility?
Yes No
If not, date of release from the review period facility

STATE/COUNTY:

INSTITUTIONAL

No

NON-INSTITUTIONAL CARE

Public

Adult foster care

Private - profit

Child foster care

Private - nonprofit

Other

Facility
Precedent:
Penal
No

Yes
Medical care
Non-medical care
Publicly operated
community residence
Public emergency
Shelter
Absence/Multiple Residences:
Dates

Form

SSA-8508 BK

(10/2008)

From

To

6

VERIFICATION

CONCLUSION

NA
Interview/contact with facility representative established the following:
INSTITUTION
SI was institutionalized (Date)

INSTITUTIONAL CARE
Public medical
Private medical
Substantial Medicaid?
Yes
No

Amount of Payment for Room and
Board

$

Other Third Party Source/Amount

$

Public or private
educational/
vocational/technical
Publicly operated
community residence

Medicaid

SI’s own income

Amount:$

Tax-Exempt organization (Church-Key Amendment applies)
Payment Excluded?

Yes

No

NON-INSTITUTION
SI was in Non-institution care
(Date)

Private nonprofit
residential care
Proprietary for
profit residential
care, educational
or vocational
training facility
Public emergency
shelter

Facility license
number/expiration date

Public correctional/
holding facility

Amount of Room and Board

$

Other third Party
Source/Amount

$

Total Cost: $
SI’s Own Income: Amount
$

NONINSTITUTIONAL
CARE

State living
arrangement:

ISM
Foster Care

Amount
$

Other Third Party (provide source and amount)

Other Contact made
Type/Date

U.S./State residency
requirement:
Met

Not Met

LA/ISM deficiency:
Yes
No

Name/Title
Place
Findings

Form

SSA-8508 BK

(10/2008)

7

SYSTEMS

SI/MI INTERVIEW

5. LA/ISM
(Household/
Transient)

Name

Household Members
Relationship to SI
Age

PA income type/SSN

CG
Entries:
LA 0
(Sharing $

)

LA 20 (Rent)
LA 22 (PA)
LA 23 (VTR)
LA 24 (Room)
LA
Other

Federal LA Codes:

State LA Codes:

State/County Codes:

J/H Income:

Form

SSA-8508 BK

RENTAL LIABILITY/HOME OWNERSHIP
Does SI live alone
Yes
Does SI (or living w/spouse)
have home ownership interest?
Does SI have rental liability?
Provide the
name/address/telephone
number of the landlord

Is the landlord related to any
household member as a parent
or child?

Does SI live in a residence
owned or rented by a nonresident of SI’s household?
Name of person in SI’s
household with rental liability, if
any and amount of payment 

No

Yes No
Amount of Mortgage: $
Yes No
Amount of Rental payment $

Yes, (to whom and how?)

No

Yes (provide name) 
No

SI/ES DO NOT HAVE HOME OWNERSHIP INTEREST OR RENTAL LIABILITY
Is SI a Transient
Yes No
Is SI a child living in parents
Yes No
HH?
Is SI in an all PA household?
Yes No
Does SI purchase/consume
Yes No
food separately?
Amount of Shelter Contribution, $
if any

Does SI Contribute towards the
Yes No
total HH expenses in a sharing
arrangement?
Amount of contribution $
Does SI Earmark Contribution
Yes No
towards the food and/or shelter
expense?
Food$
Shelter$
SI lives with others and makes
Yes No
no contribution towards the HH
expenses?
Are services required by
Yes No
owner?

(10/2008)

8

SI/MI HOUSEHOLD INTERVIEWS

Type

Average Household Expenses
Amount ($)

Description of Evidence

Food
Rent
Mortgage
(including property Insurance)
Property Tax (Yr/Monthly amount)
Heating/Fuel
Gas
Electricity
Water
Sewer
Garbage Removal
TOTAL
Above Averages are for:

If SI or living w/spouse has ownership interest or rental liability, what is the amount of contributions from other HH
members if any?
$

Does SI receive contributions from outside the HH? Yes No
If yes, provide the following:
Name/Address/Telephone of person that SI is receiving contributions from
(SSA 795 in file)

Amount
$

Does SI receive a housing subsidy?
If so, what is the source of the subsidy

What is the amount of the subsidy, if
known?

What is the length of time at the review
period residence?

Last date SI/ES was out of the U.S.

Yes

No

Unknown

Temporary absence by SI or any HH
member

Form

SSA-8508 BK

(10/2008)

9

SI/MI HOUSEHOLD INTERVIEWS
Has the SI resided at the current residence address for the entire review period?
If not, complete the applicable living arrangement changes below:

Yes

No

Changes in household composition in review period:

Changes in household expenses in review period:

Changes in LA in review period:

Form

SSA-8508 BK

(10/2008)

10

VERIFICATION

CONCLUSION

LA/ISM/Residency established during interview with SI/other household members.

Basis for Federal LA

Home ownership:
Title
Life estate
Unprobated estate
Trust

Collateral sources contacted
Name/Telephone #
Date

Rental liability
Rent
$
CMRV $
Flat fee $
Room rental
Commercial
establishment
Non-commercial

Type of contact
Findings

SSA 795 in file pertaining to HH expenses
Bills/Receipts of HH expenses were requested for the past 12 months, but were not
available

PA household
Separate consumption
Separate purchase

Bills/Receipts were available for
QRA Determination

Sharing

Number of HH
members
Total HH Expenses

Earmarked sharing
food/shelter

SI’s Pro-rata share

Transient

SI’s Contribution

Intervening A
VTR applies

Other HH Member’s
Contribution

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

Inside ISM (including
VTR)
Outside ISM

Basis for State LA:

LA/ISM FOR:
Living Arrangement

Review Period
Month

Inside ISM: $

ISM $

Outside ISM: $

CM

U.S./State Residency

IM

Requirement:
Met
Not Met

BM

LA/ISM deficiency:
No
Yes

Last Date SI/ES outside U.S.

Form

SSA-8508 BK

(10/2008)

11

SYSTEMS

6. UNEARNED
INCOME

SI/MI INTERVIEW
NOTE: Only BM allegations need be shown if no income changes are alleged for
review period.
SI Allegation

CM

IM

BM

MI Allegation

CM

IM

BM

Title XVI

$

$

$

Title XVI

$

$

$

SI:
Fed:

Title II

$

$

$

Title II

$

$

$

State:

VA Pension

$

$

$

$

$

$

CM:
IM:
BM:
Retro:

VA Compensation

$

$

$

VA
Compensation

$

$

$

$

$

$

Railroad
Retirement

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

State Disability
Payments
Foster Care

$

$

$

$

$

$

$

$

$

State Disability
Payments
Foster Care

$

$

$

Energy Assistance

$

$

$

$

$

$

Unemployment
Compensation
Workers Comp

$

$

$

$

$

$

$

$

$

Energy
Assistance
Unemployment
Compensation
Workers Comp

$

$

$

Sick P y

$

$

$

Sick Pay

$

$

$

Education
Assistance
Dividends/Royals

$

$

$

$

$

$

$

$

$

$

$

$

Rental Income

$

$

$

Education
Assistance
Dividends/Royal
s
Rental Income

$

$

$

Interest

$

$

$

Interest

$

$

$

Gifts

$

$

$

Gifts

$

$

$

Loans

$

$

$

Loans

$

$

$

Support from
absent parent
Other Cash
Support
Gambling Income

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Support from
absent parent
Other Cash
Support
Gambling
Income

$

$

$

Miscellaneous

$

$

$

Miscellaneous

$

$

$

Title XVI

Railroad
Retirement
Govt. Pension

MI:
CM:
IM:
BM:
Retro:

Black Lung

Title II
SI:

CM:
IM:
BM:
Retro:
MI:
CM:
IM:
BM:
Retro:
Other
SI:
CM:
IM:
BM:
Retro:
MI:
CM:
IM:
BM:
Retro:

A Pension

Govt. Pension
Black Lung

1099 ALERT:
Title XVI Recoup:

Form

SSA-8508 BK

Evidence Viewed:

(10/2008)

12

VERIFICATION

CONCLUSION

FINDINGS
Title XVI
VA

Title II
OPM

RRB

Black Lung

Verified by SSR - no reason to doubt

Unearned income
did not cause an
error in the
sampled payment.

Verified by award letter or other evidence in SI's possession
The following
unearned income
amount caused a
payment error:
$

Collateral Contact Made
Type/Date
Name/Title/Organization
Income/Income
Exclusion established
Amounts

CM: $

IM: $

CM: $

IM: $

BM:$

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

Type/Date
Name/Title/Organization
Income/Income
Exclusion established
Amounts

CM

BM:$
Unearned income
exclusion applies
to SI/ES’s budget
month income:

Interest income, see Element 8.
$

IM

$

BM

$

Ineligible child with unearned income
Name of Child
Source of Income
Type of Income
Deeming applies
Verified by
Amounts

CM: $

IM: $

BM: $

Excluded court ordered support payments made by ineligible spouse/parent
Unstated income suspected/confirmed:
Form

SSA-8508 BK

(10/2008)

13

SYSTEMS
7. WORK HISTORY
EARNED INCOME

SI/MI INTERVIEW
Last date of employment: SI
Employment history for 3 yrs. ending with sample month:
Sampled Individual
Employer Name/Address or Self Employment

MI

Dates

Military:

Total quarters
from SER:

Year last
worked from
SER:

Material Individual
Employer Name/Address or Self Employment

Dates

1099 Alert:

SSR Wages:
SI:
CM:
IM:
BM:

MI:
CM:
IM:
BM:

SEI:

Review Period
Earnings

Earned Income Exclusions?
Work expenses of BWE
PASS
Court Ordered Payments

None
IRWE
Student child earned income
Cafeteria Plan

Type
Amount
Frequency

Earned Income
Exclusions:

Source

Employment history prior to last 3 years
Employer Name/Address or Self Employment

Does the SI have a Union membership?

Dates

Yes (union ID)

No

Does the SI have Military Service?

Yes (dates of service)

No

Does the SI have a pending claim/prior
denial for benefits based on work/military
services?

Yes (explain)

No





Form

SSA-8508 BK

(10/2008)

14

VERIFICATION

CONCLUSION

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

No potential
entitlement to
other benefits

Potential
entitlement
established for:

Collateral contact made:
Source
Ty e

No earned
income in the
review period

Date
Findings

CM: $

IM: $

BM:$
Review period
earnings - no
payment error

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

Earned income
caused payment
error: $

See employer contact in file.
See summary of SI/MI's records.
See SSA-795
See summary/copy of other business record in file.
Gross wages:
CM

Following
earned income
exclusions apply:

$

IM

$

BM

$

No earned income
exclusions apply

Net Earnings from Self-Employment
Amount
$
Year

Deeming applies

Earned Income Exclusions Established:
Type
Amount/frequency
Established by

Ineligible Child with Earnings
Name
Amount

CM $

IM $

BM $

Verified by

Form

SSA-8508 BK

(10/2008)

15

SYSTEMS
8. LIQUID
RESOURCES

Direct Deposit
BCR:
BCA:
Name:

1099 Alert:

CG Entries:
RE01
RE04
RE08
RE21
RE

SV
CK
CD
Svgs Bds

SI/MI INTERVIEW
Allegations
Patient Account
Checking account
Savings account
Credit Union
Oth. Bank accts
(Christmas club, etc).
CD
Savings Bonds
Promissory Notes
Stocks/Bonds
Mutual Funds
Prepaid burial plan
Safe Deposit
Trusts
401(k) plans/Keough accts
LI Dividend Accumulations
Cash on hand



Positive Allegation
Account Type/
Account Number

SSI Direct Deposit

SI

MI
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CM:$

No
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CM:$

No
No
No
No
No
No
No
No
No
No

IM: $

IM: $

BM:$

BM:$

Financial Institution

Balances
($)

Owner Name
SI

MI

SI

MI

SI

MI

SI

MI

T2 Direct Deposit

Check Cashing Location, if no Direct
Deposit alleged
If SI/MI do not have SSN, Provide the Tax
ID Number (TID)
Is SI/MI’s name on anyone else’s bank
account? If so, provide name

Form

SSA-8508 BK

Prior accounts in the last 24 months?

Yes

No (if yes, show FI name and location):

Place where funds are kept for burial
NA
Other financial institutions used to transact
business i.e., personal loans, mortgages
Deposits made by joint owner?

Yes

No if yes, provide Name/Date/Amt

(10/2008)

16

VERIFICATION
Findings
Acct Type/Acct #

Financial Institution

CONCLUSION

Owner Name

Balances
CM
IM
BM
Interest

Yes

No

If yes, see element 6

CM
IM
BM
Interest

Yes

No

If yes, see element 6

CM
IM
BM
Interest

Yes

Yes

Liquid resources
caused or contributed
to ineligibility for
the sampled payment

No

If yes, see element 6

CM
IM
BM
Interest

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

Total countable
liquid resources
on first day of
sample month:

No

If yes, see element 6

CM
IM
BM
Interest

MI

Checking:

Yes

No

If yes, see element 6

CM
IM
BM
Interest

SI

Savings:
Other:
Total:

Yes

No

If yes, see element 6

CM
IM
BM
Interest

Yes

No

If yes, see element 6

Geo Search did not identify additional accounts

Other Liquid Resource Findings
TYPE

Form

SSA-8508 BK

BALANCES

(10/2008)

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

17

SYSTEMS

9. REAL PROPERTY

RE Field Entries

SI/MI INTERVIEW
Allegation of real property ownership by SI/MI:
Home Property Ownership Yes No
Home Property Type
Non-Farm

Farm

Trailer/Mobile Home

Other

Ownership
SI is Sole Owner (non-life estate)
Jointly owned with Spouse
Jointly owned with non-relative
Unprobated Estate

MI is Sole Owner (non-life estate)
Jointly owned with relative (non-spouse)
Life Estate
Other
(equitable ownership, remainder interest, etc)
Non-Home Property Ownership Interest:
Yes
No
Type
Owner
Loan Alleged
CMV
Farmland (rented)
$
$

CG Entries

Farmland
(used by SI)

$

$

Commercial
(non-farm) or
residential property,
rented
Non-Excluded
previous or second
residence (not
rented)
Unimproved land,
idle

$

$

$

$

$

$

Foreign property

$

$

Other (mineral,
timer, water rights,
easements, etc)
Unknown (type
cannot be
determined)
Evidence of
Ownership/Value

$

$

$

$

$

$

Burial
Plot/Crypt/Location/
Value Designated
for
Transfer of property since 12/14/1999?
Yes No

Attempt to Dispose of Property?

Income producing Property?

Form

SSA-8508 BK

(10/2008)

If transfer of ownership alleged, provide the
following: Type of real property/Name and
address of recipient of property/date of
transfer/Reason for the transfer/monetary or
other compensation received.
(Document on SSA 795)
Yes No

Yes

No

18

VERIFICATION
Allegations Verified by Government Records:

Alpha listing Contact method:

Personal Visit

Letter

CONCLUSION

Telephone

Date of Contact

Internet

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

Name of Contact

Title of contact

Findings:
No property ownership found

Ownership Discovered

Owner

Owner

Location

Location

CMV
(duration of
ownership)

CMV
(duration of
ownership)

SI/MI owns
nonexcluded real
property valued
at:
$

SI/MI owns
excluded other
property (ex.
burial plot)

Other Collateral contact made:
Type Contact/Date

Findings

Form

SSA-8508 BK

(10/2008)

19

SYSTEMS
10. VEHICLES

SI/MI INTERVIEW
Positive allegation

None alleged

Year/Make

Yr/Make
Year/Make

RE Field Data

CG Entries

Model

Model

Condition

Condition

Owner

Owner

Use

Use

VIN

VIN

License #

License #

Transfer
Alleged
Evidence
Viewed
Encumbrances

Yes

No

Year/Make

SSA-8508 BK

Model

Condition

Condition

Owner

Owner

Use

Use

VIN

VIN

License #

License #
Yes

No

Transfer
Alleged

Evidence
Viewed

Evidence
Viewed

Encumbrances

Encumbrances

(10/2008)

Yes

No

Yr/Make
Year/Make

Model

Transfer
Alleged

Form

Transfer
Alleged
Evidence
Viewed
Encumbrances

Yes

No

20

VERIFICATION

CONCLUSION

FINDINGS:
No reason to doubt negative allegations
N.A.D.A. value(s):
Vehicle #1
$
Vehicle #2

$

Vehicle #3

$

Vehicle #4

$

See SSA-795 regarding vehicle use.

No vehicle ownership by SI/MI
Vehicle exclusion
applies:
Transportation
Employment
Other
Total vehicle value
$
Non-excluded value
$

Collateral contact made:
Name
Type/Contact/Date
Findings

Form

SSA-8508 BK

(10/2008)

21

SYSTEMS
11. LIFE
INSURANCE

RE Field Data

SI/MI INTERVIEW
Positive Allegation

None Alleged

Insurance Company
Name
Policy Number
Issue Date
Owner

Insurance Company Name
Policy Number
Issue Date
Owner

Face Value

$

Face Value

$

Cash Value

$

Cash Value

$

Outstanding Loans?
CG Entries

Yes

No

Age at Issue

Age at Issue

Premium
amount/frequency

Premium amount/frequency

Type of Policy

Type of Policy

No

Yes

No

Fully paid Policy?

Yes

No

Policy Viewed?

Yes

No

Policy Viewed?

Yes

No

Yes

No

Does policy produce
Dividend additions or div
accumulations

Yes

No

Does policy produce
Dividend additions or div
accumulations

Transfer alleged

Yes

No

Transfer alleged

Yes

No

Accelerated life
insurance payments?

Yes

No

Accelerated life insurance
payments?

Yes

No

Yes

No

Insurance Company Name
Policy Number
Issue Date
Owner

Face Value

$

Face Value

$

Cash Value

$

Cash Value

$

Outstanding Loans?

SSA-8508 BK

Yes

Fully paid Policy?

Insurance Company
Name
Policy Number
Issue Date
Owner

Form

Outstanding Loans?

Yes

No

Outstanding Loans?

Age at Issue

Age at Issue

Premium
amount/frequency

Premium amount/frequency

Type of Policy

Type of Policy

Fully paid Policy?

Yes

No

Fully paid Policy?

Yes

No

Policy Viewed?

Yes

No

Policy Viewed?

Yes

No

Yes

No

Does policy produce
Dividend additions or div
accumulations

Yes

No

Does policy produce
Dividend additions or div
accumulations

Transfer alleged

Yes

No

Transfer alleged

Yes

No

Accelerated life
insurance payments?

Yes

No

Accelerated life insurance
payments?

Yes

No

(10/2008)

22

VERIFICATION

CONCLUSION

No Reason to doubt negative allegations

No life insurance
ownshp by SI/MI

Collateral contact made
Company
Name

Company
Name

Policy
Number

Policy
Number

Owner
Name

Owner
Name

Total
Face
Value
Total CSV

$

Dividend accum.
value
Face value does
not exceed $1500
per insur. indiv.
Total CSV is

Total Face
Value

$

Total CSV

CM

SI

MI

CM

CM

IM

BM

IM

BM

IM
BM

Company
Name

Company
Name

Policy
Number
Owner
Name

Policy
Number
Owner
Name

Total
Face
Value
Total CSV

$

Retro

Face value
exceeds
$1,500
per insured.

Total Face
Value

$

Total CSV

CM

Countable CSV
value of life ins
SI

CM

IM

BM

IM

BM

MI

CM
IM

CSV/Dividends set aside for burial (See SSA -4169/SSA 795 in file)
Dividends paid? Yes No (if yes, see Element 6)

BM
Retro

Ownership
CSV dividends
set aside for burial

Pertinent Values
Dividend
Accumulation values

Form

SSA-8508 BK

(10/2008)

23

SYSTEMS
12. RESOURCES
SUMMARY/OTHER
NONLIQUID
RESOURCES

SI/MI INTERVIEW
Does SI own any other non-liquid resources, (items of unusual value)?
If so, indicate below:

Yes

No

Transfer alleged

Income producing

Encumbrances

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

13. REPRESENTATIVE
PAYEE
Selection Date:
T:
CO:
CU:
Name:

No alleged or observed need for payee development/change.

Payee development suggested by:

14. FRAUD

No fraud suspected

Fraud suspected before or during interview due to:

Form

SSA-8508 BK

(10/2008)

24

VERIFICATION

No reason to doubt negative allegation

CONCLUSION

Total non excluded
resource values:

Collateral contacts made:
Name

Liquid
SI

MI

CM

Type contact/Date

IM
BM

Findings

Retro

Non Liquid
SI

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

MI

CM
IM
BM
Retro

Deeming applies

Resources cause ineligibility:
No

No payee development required

Yes

FO payee development
required

Referred to field office for payee development
No development
required

Name
Contact type/date
Findings

No development required

No fraud
suspected

Fraud referred due to:
Fraud
referral made

Form

SSA-8508 BK

(10/2008)

25

SUPPLEMENTAL DOCUMENTATION
15.DEATH OF MI
DH

Name
Relationship to SI
Date of Death
Evidence viewed
16. STUDENT STATUS
Student Name

Student Name

Sch. Name

Sch. Name

Sch. Address

Sch. Address

Dates of
Attendance
Full time

Dates of
Attendance
Full time

Yes

No

Evidence
Viewed

17. AGE

Yes

No

Evidence
Viewed

Evidence presented by SI/MI, or derived from collateral contact

Eligible Children
Name

Name

Name

SSN

SSN

SSN

DOB

DOB

DOB

Ineligible Children
Name

Name

Name

SSN

SSN

SSN

DOB

DOB

DOB

Mth
Name
Fth
Name
Evidence
Viewed

Mth
Name
Fth
Name
Evidence
Viewed

Mth.
Name
Fth
Name
Evidence
Viewed

18. RELATIONSHIP
Ineligible child of SI
Ineligible sibling of SI
Parent to eligible child

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

Place

Spouse as parent to eligible child
Alien sponsor to spouse/dependents
Other

Form

SSA-8508 BK

(10/2008)

26

VERIFICATION
None required

CONCLUSION
Payment effect
$

Collateral Contact made
Name

PYMT deficiency

Contact type/date

Nonpayment
deficiency

Finding
Evidence Viewed

No discrepancy

None required
Collateral Contact made
Name

Student Status
verified

Contact type/date
Finding
Evidence Viewed

Numident in file IDN

No discrepancy

Collateral Contact Made

Age Verified

Name
Contact type/date
Finding
Evidence Viewed

No discrepancy

Numident in file
Collateral Contact made
Name

Relationship
verified

Contact type/date
Finding
Evidence Viewed

Form

SSA-8508 BK

(10/2008)

27

REMARKS/DEFICIENCY ANALYSIS

Reviewer's Signature

Form

SSA-8508 BK

Date

(10/2008)

28

Privacy Act Statement Collection and Use of Personal Information
Sections 205(a), 1611(c)(1), 1631(d) and (e)(1)(B) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to help us determine the individual’s eligibility for
See Revised Privacy Act Statement Attached
benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may
prevent us from making an accurate and timely decision on any claim for benefits.
We rarely use the information you supply for any purpose other than to complete our claims process. However, we
may use the information for the administration of our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy
Act System of Records Notices 60-0040, entitled Quality Review System, 60-0042, entitled Quality Review Case
Files, and 60-0057, entitled Quality Evaluation Data Records. Additional information about these and other system
of records notices and our programs is available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.
We may share the information you provide to other health agencies through computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or local government agencies.
We use the information from these programs to establish or verify a person’s eligibility for federally funded or
administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.
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 30 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 21235-6401.

Form

SSA-8508 BK

(10/2008)

29