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

Added text boxes in place of lines

Form Approved
OMB No. 0960-0133

SUPPLEMENTAL SECURITY INCOME - QUALITY REVIEW CASE ANALYSIS
SSN:

State of Residence:

SM:

ES SSN:

AIPQB:
SSA-FO code:

Title XVI Stewardship
Case Excluded? Yes
Exclusion code:

Removed
"Type of
Review"

No

moved to the top

SSR DOCUMENTATION

FIELD REVIEW DOCUMENTATION
1. Interview Date

1. Name of Sampled Individual

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 (06-2006) EF (06-2006)

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.

Page 1 of 26

SYSTEMS
1. SSN

SI/MI INTERVIEW
Allegation/evidence agrees with SSR
Different or additional SSN/names found

SI:
ES:

Evidence viewed:
SS card

Medicare card

Photo Identification

Verified:
Other
Removed "File includes POMS development required when SSN not issued prior to age 12."

Allegation
2. AGE
CITIZENSHIP/
LEGAL ALIEN
STATUS/IDENTITY

SI

Name on Record

ES

Added chart format

Date of Birth
Date of Birth
SI:

Place of Birth

Parents Names

Mth:

Mth:

Fth:

Fth:

ES:
Type of Evidence

Issuing Agency

BIC
SI:

Date Recorded

Date/Place Issued

ES:

Alien Status

AR CODE
SI:

U.S. Entry Date

Port of Entry

Country of Origin

ES:

Alien Reg. # /
Class code
Card Expiration
Date

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 2 of 26

VERIFICATION

CONCLUSION

SSN verified via SS card/Medicare card

No SSN
discrepancy

SSN verified via systems query (in file).

Multiple SSNs
found but
payment not
affected

Issue date

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

Allegation accepted. Age is not material.

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

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

Added check boxes

Removed "No material age
discrepancy."

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

Yes

Citizenship/
Legal Alien
Status
requirement met

No
Added block

U.S. born
Naturalized
Collateral Contact Made
Type/date

Alien

Place

Refugee
Other

Name/Title

added block

Does not meet
Citizenship/Alien
Status

Findings

Removed "Material
discrepancy found"

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 3 of 26

SYSTEMS

SI/MI INTERVIEW
Marital History: (including parents of minor child) None

3. MARITAL STATUS
CODE:

Spouse
or
Parents

Name

Added table format

Spouse Shown:
No

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

Added block

Event

Requests DOB/POB/mothers
maiden name if SSN is
unknown

Married
Created checkboxes for the
Divorce
Separated event column
Widowed

Spouse

Yes

Parents

Created spouse
and parents

Name:

checkboxes

Married
Divorce
Separated
Widowed

Spouse
Parents

Parents Shown:

Married
Divorce
Separated
Widowed

Spouse
Parents

No

Yes

Names:

Married
Divorce
Separated
Widowed

Spouse
Parents

Evidence Viewed

Date

Created text box for Evidence Viewed information,
and removed "Type," "Names," "Event date," "Issue
Date," and "Issuing Agency."

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
Added request for DOB

Added Yes/No
checkboxes

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

Added block
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

(06-2006) EF (06-2006)

Added block

Page 4 of 26

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)
Removed "Material

See SSA-795s/4178s in file

discrepancy found"

Other evidence

Potential T2
Entitlement
Referral:

Added check
box

Potential Title II Entitlement established:
Yes

Name

No

SSN

Type

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 5 of 26

SYSTEMS

SI/MI INTERVIEW
NA

Added block

Facility Name/Address
4. LA/ISM
(Non Household)

Facility Representative
Name/Title
Type of Contact/Date

CG:
Date of Admissions to the review period facility

FEDERAL LA
CODES:

Did the SI actively participate in the interview?

Yes

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

No

Added block

STATE LA CODES:
Removed "Last date SI/ES was out of U.S." and "Number of residences over last 3 years."

INSTITUTIONAL

STATE/COUNTY:

NONINSTITUTIONAL CARE

Public

Adult foster care

Private - profit

Child foster care

Private - nonprofit

Other

Penal
Facility
Precedent:
No

Medical care
Yes

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

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Created table format

From

To

Page 6 of 26

VERIFICATION

NA

CONCLUSION

Added block

Interview/contact with facility representative established the following:
Created table

INSTITUTION
SI was institutionalized (Date)

Substantial Medicaid?
Yes
No

Removed "Size/number of residents"

Amount of Payment for Room and
Board

$

Other Third Party Source/Amount

$

Medicaid

SI’s own income

Public or private
educational/
vocational/technical
Replaced "Total monthly cost" with
"Other Third Party Source/
Amount" (moved from below "TaxExempt organization"

Amount:$

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

Yes

No

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

Removed "Placement By" and "Supervised By"

Facility license
number/expiration date
Amount of Room and Board

INSTITUTIONAL CARE
Public medical
Private medical

Publicly operated
community residence
Private nonprofit
residential care
Proprietary for
profit residential
care, educational
or vocational
training facility
Public emergency
shelter
Public correctional/
holding facility

$
Placed "Amount of pymnt for room and board" here

Other third Party
Source/Amount

$
Added space for "Other third party source/amount" here

Total Cost: $
Removed "Amount of pymt for room and board"

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

(06-2006) EF (06-2006)

Page 7 of 26

SYSTEMS

SI/MI INTERVIEW
Created table

5. LA/ISM
(Household/
Transient)

Name

Household Members
Relationship to SI
Age
PA income type/SSN
Added request for 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
Yes
Does SI live alone
Does SI (or living w/spouse)
have home ownership interest?
Does SI have rental liability?
Provide the
name/address/telephone
number of the landlord
Æ
Is the landlord related to any
household member as a parent
or child?
Æ
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 Æ

Applies only if SI/Spouse has

No

rental liability/home ownership

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

Yes, (to whom and how?)

No

Yes (provide name) Æ
No

SI/ES DO NOT HAVE HOME OWNERSHIP INTEREST OR RENTAL LIABILITY
Yes No
Is SI a Transient
Applies only when SI/Spouse do not
Is SI a child living in parents
Yes No
have rental liability/home ownership
HH?
Is SI in an all PA household?
Yes No
Does SI purchase/consume
Yes No
food separately?
Amount of Shelter Contribution, $
if any
Æ
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?

(06-2006) EF (06-2006)

Page 8 of 26

SI/MI HOUSEHOLD INTERVIEWS
Average Household Expenses
Amount ($)

Type

Description of Evidence

Food
Rent
Mortgage
(including property Insurance)
Property Tax (Yr/monthly amount)

Added "Yr/monthly amount"

Heating/Fuel
Gas
Electricity
Water
Sewer
Garbage Removal
TOTAL
Above Averages are for:
Removed "Household member(s) not contacted because______

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 Revised language: substituted "contributions" for "food/shelter."
If yes, provide the following:
Name/Address/Telephone of person that SI is receiving contributions
Amount
from. (SSA 795 in file)
$

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

Yes

No

Unknown

Added request for the source

Removed: "Number of residences during last 3 years."

Removed: "Amount of cash contributions and loans of ISM $________ (see SSA-795 in file)."

Temporary absence by SI or any HH
member

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 9 of 26

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: Added question

Yes

No

Removed the blocks that indicated "None" for each statement below.

Changes in household composition in review period

Changes in household expenses in review period

Changes in LA in review period

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 10 of 26

VERIFICATION

CONCLUSION

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

Home ownership:
Title
Life estate
Unprobated estate
Trust

Collateral sources contacted
Name/Telephone #
Date
Type of contact
Findings
Removed "La/ISM Established" as it is redundant; and removed section on "average household expenses"

SSA 795 in file pertaining to HH expenses

Basis for Federal LA

Added blocks

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

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

Added table

Number of HH
members

Sharing

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

Created table for this information

ISM $

Inside ISM: $
Outside ISM: $
U.S./State Residency

CM

Requirement:
Met
Not Met

IM

LA/ISM deficiency:
No
Yes

BM

Last Date SI/ES outside U.S.

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 11 of 26

SYSTEMS

SI/MI INTERVIEW
NOTE: Only BM allegations need be shown if no income changes are alleged for
Created table for this information and reordered some of the categories
review period.

6. UNEARNED
INCOME
Title XVI
SI:
CM
IM
BM
Retro

SI Allegation

CM

IM

BM

MI Allegation

CM

IM

BM

Title XVI

$

$

$

Title XVI

$

$

$

Title II

$

$

$

Title II

$

$

$

$

$

$

$

$

$

$

$

$

VA
Compensation

$

$

$

$

$

$

Railroad
Retirement

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

State Disability
Payments
Foster Care

$

$

$

$

$

$

$

$

$

$

$

$

Removed "Bank Deposits"

VA Pension
VA Compensation

MI:
CM
IM
BM
Retro

Railroad
Retirement
Govt. Pension
Removed "Private Pension"

Black Lung

Title II

State Disability
Payments
Foster Care

SI:
CM
IM
BM
Retro

Govt. Pension
Black Lung

Removed "Assistance Based on Need"

MI:
CM
IM
BM
Retro
Other
SI:
CM
IM
BM
Retro
MI:
CM
IM
BM
Retro
1099 ALERT:

Title XVI Recoup:

Energy Assistance

$

$

$

Unemployment
Compensation
Workers Comp

$

$

$

$

$

$

Energy
Assistance
Unemployment
Compensation
Workers Comp

Sick Pay

$

$

$

Sick Pay

$

$

$

Education
Assistance
Dividends/Royals

$

$

$

$

$

$

$

$

$

Education
Assistance
Dividends/Royals

$

$

$

Rental Income

$

$

$

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

$

$

$

Evidence Viewed:

Form

VA Pension

SSA-8508 BK

Added block for this informaiton

(06-2006) EF (06-2006)

Page 12 of 26

VERIFICATION
FINDINGS

CONCLUSION

Organized the information on this page in tables

Added Title "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
Removed block for "Place"

Name/Title/Organization
Added "Organization"

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

Income/Income
Exclusion established
Amounts

CM: $

IM: $

BM:$

Added blocks for "Amounts"

Type/Date
Removed block for "Place"

Name/Title/Organization
Added "Organization"

Income/Income
Exclusion established
Amounts

CM: $

IM: $

BM:$

Added blocks for "Amounts"

CM

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

Added "Source"

Deeming applies
Verified by
Amounts

Added "Deeming"

CM: $

IM: $

BM: $

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

SSA-8508 BK

(06-2006) EF (06-2006)

Moved to bottom of page

Page 13 of 26

SYSTEMS

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

7. WORK HISTORY
EARNED INCOME

MI

Dates

Military:
Removed "Type of Work" and "Employee"

Total quarters
from SER:
Year last
worked from
SER:

Created table
Material Individual
Employer Name/Address or Self Employment

Dates

1099 Alert:
Removed "Type of Work" and "Employee"

SSR Wages:
SI:
CM
IM
BM

Review Period
Earnings

Removed "Retro: Y__N__"

Removed "Evidence"

MI:
CM
IM
BM

Earned Income Exclusions?

None
Added blocks

Work expenses of BWE
PASS
Court Ordered Payments

Removed "Retro: Y__N__"

SEI:

IRWE
Student child earned income
Cafeteria Plan

Type
Amount
Frequency

Earned Income
Exclusions:

Source
Employment history prior to last 3 years Reorganized as a table
Employer Name/Address or Self Employment
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

Does the SI have a Union membership?
Æ
Added "Yes/No" checkboxes as well
as request for "union ID," "dates of
service," and explanation of pending
claim

Æ
Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 14 of 26

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
Collateral contact made:
Source

Created table; added spaces for amounts

No potential
entitlement to
other benefits

Potential
entitlement
established for:

Type
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
Removed "See summary/copy of tax return"

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

(06-2006) EF (06-2006)

Page 15 of 26

SYSTEMS

SI/MI INTERVIEW
Removed "Type of Resource"

8. LIQUID
RESOURCES

Direct Deposit
BCR:
BCA:
Name:

1099 Alert:

CG Entries:
RE01
RE04
RE08
RE21
RE

SV
CK
CD
Svgs Bds

Added Yes and No blocks for each type of source, and reordered list

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

Æ

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: $

added spaces for different

BM:$

BM:$

amounts of cash on hand

Positive Allegation Added space for this section
Account Type/
Financial Institution
Account Number

Added blocks, and removed "No accounts alleged"

SSI Direct Deposit

Balances
($)

Owner
Name
SI

MI

SI

MI

SI

MI

SI

MI

Removed "ID" and "Encumbrances"

T2 Direct Deposit

Check Cashing Location, if no Direct
Deposit alleged
If SI/MI do not have SSN, Provide the Tax
ID Number (TID)
Restated question

Removed "Miscellaneous";

IM: $

Reordered requested information

Added space to provide TID

Is SI/MI’s name on anyone else’s bank
account? If so, provide name
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

Removed "mortgage, pers, loan from"

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 16 of 26

Removed "SI has been in an institution/non institutional care facility for at least 3 years- no reson to doubt negative allegation" and
"Collateral contact made (Include patient account)"

VERIFICATION

Findings
Acct Type/Acct #

Financial Institution

Owner Name

CM
IM
BM
Interest Yes No
If yes, see element
8
CM
IM
BM
Interest Yes No
If yes, see element
8
CM
IM
BM
Interest Yes No
If yes, see element
8
CM
IM
BM
Interest Yes No
If yes, see element
8
CM
IM
BM
Interest Yes No
If yes, see element
8
CM
IM
BM
Interest Yes No
If yes, see element
8
CM
IM
BM
Interest Yes No
If yes, see element
8

Reorganized section to better record findings

Added block

Balances

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

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

Total countable
liquid resources
on first day of
sample month:
SI
Checking:

Savings:
Other:

Total:

Geo Search did not identify additional accounts

Other Liquid Resource Findings

Included table to record other
types of liquid resources

TYPE

Form

SSA-8508 BK

BALANCES
CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

(06-2006) EF (06-2006)

Page 17 of 26

MI

VERIFICATION
CM: $
IM: $

CONCLUSION
BM: $

Page 17 will be shown on one page only once SSA's Forms Management Team
formats the revised SSA-8508 (See Note on Addendum).

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 17 of 26

SYSTEMS

9. REAL PROPERTY

RE Field Entries

SI/MI INTERVIEW
Allegation of real property ownership by SI/MI:
Home Property Ownership Yes No Added block; removed "None"
Home Property Type
Non-Farm

Farm

Trailer/Mobile Home

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

Non-Home Property Ownership Interest:
Type
Owner
Farmland (rented)
Reorganized as chart
for ease of recording

CG Entries

Removed "Commercial
property (non-farm) used by
SI or MI," "CMV" and
"Encumbrances"; and added
"Burial Plot/Crypt/Location/
Value Designated for" into
the chart.

Yes
Loan Alleged

No

Added "Yes/No" blocks

CMV
$

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
Added date.

Income producing Property?

SSA-8508 BK

MI is Sole Owner (non-life estate0
Jointly owned with relative (non-spouse)
Life Estate
Other
(equitable ownership, remainder interest, etc)

$

Attempt to Dispose of Property?

Form

Other

(06-2006) EF (06-2006)

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

Page 18 of 26

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

VERIFICATION

CONCLUSION
No real property
ownership
established for SI/MI

Allegations Verified by Government Records:
Added blocks

Alpha listing Contact method:

Personal Visit

Letter

Telephone

Internet
SI/MI owns
excluded home
property

Date of Contact

Name of Contact

Title of contact

Findings:
No property ownership found

SI/MI owns
nonexcluded real
property valued
at:
$
Ownership Discovered

Removed "Nonhome (including burial plot) ownership"; and "Nonhome (including non-excluded burial plto) ownership"

Owner

Owner

Location

Location

CMV
(duration of
ownership)

CMV
(duration of
ownership)

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

Other Collateral contact made:
Type Contact/Date

Findings

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 19 of 26

SYSTEMS

SI/MI INTERVIEW
Reorganized as table

Positive Allegation
10. VEHICLES

RE Field Data

None Alleged

Year/Make

Year/Make

Model

Model

Condition

Condition

Owner

Owner

Use

Use

VIN

VIN

License #

License #

CG Entries

Transfer
Alleged
Evidence
Viewed
Encumbrances

RE 1

Yes

No

Transfer
Alleged
Evidence
Viewed
Encumbrances

Yes

No
Removed "Title," "Regist." and "other"

Removed "Additional information to verify value/use/ownership,"
"Handicapped equipped," and "Duration of ownership"

11. LIFE
INSURANCE

RE Field Data

Positive Allegation
Insurance
Company Name

Insurance
Company Name

None Alleged

Policy Number

Policy Number

Issue Date
Owner

Issue Date
Owner

Removed "Insured" from chart

Face Value

$

Face Value

$

Cash Value

$

Cash Value

$

CG Entries
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

Yes

No

Removed "If the policy is not paid up, what is the premium amount etc." and "If yes, does supplemental contract exist?"

Policy Viewed?

Yes

No

Policy Viewed?

Yes

No

Yes

No

Removed "Inf. Allgd" and "Particip" from below "Policy Viewed"

Does policy
produce Dividend
additions or div
accumulations

Form

SSA-8508 BK

Does policy
produce Dividend
additions or div
accumulations

Yes

No

Transfer alleged

Yes

No

Transfer alleged

Yes

No

Accelerated life
insurance
payments?

Yes

No

Accelerated life
insurance
payments?

Yes

No

(06-2006) EF (06-2006)

Removed need to list the premium amount and frequency of
payment for a policy that is not paid up

Page 20 of 26

VERIFICATION
FINDINGS:
No reason to doubt negative allegations
Removed "Encumbrances" block

N.A.D.A. value(s):
Vehicle #1
$
Vehicle #2

$

Vehicle #3

$

Vehicle #4

$

Created a chart for vehicle usage information

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

See SSA-795 regarding vehicle use.
Collateral contact made:

Non-excluded value
$

Name
Replaced "Value under

Type/Contact/Date

limit" with "Transportation"

Findings

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 21 of 26

VERIFICATION
No Reason to doubt negative allegations
Created Chart for this information; made room for four
Collateral contact made
Policies to be listed.

CONCLUSION
No life insurance
ownshp by SI/MI

Company
Name

Compan
y Name

Dividend accum.
value

Policy
Number
Owner
Name

Policy
Number
Owner
Name

Face value does
not exceed $1500
per insur. indiv.

Total Face
Value

Total
Face
Value
Total
CSV

Total CSV

CM

IM

BM

Company
Name

Company
Name

Policy
Number
Owner
Name

Policy
Number
Owner
Name

Total Face
Value

$

Total CSV

CM

IM

BM

Total
Face
Value
Total CSV

Total CSV is
SI
CM:
CM

IM

BM

MI

IM:

BM:
Retro
Face value
exceeds
$1,500
per insured.
$

CM

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

IM

BM

Countable CSV
value of life ins
SI
MI
CM:
IM:

BM:
Ownership

Retro

Pertinent Values
Dividend
Accumulation values

Form

SSA-8508 BK

(06-2006) EF (06-2006)

CSV dividends
set aside for burial

Page 21 of 26

SYSTEMS
12. RESOURCES
SUMMARY/OTHER
NONLIQUID
RESOURCES

SI/MI INTERVIEW
Does SI own any other non-liquid resources, (items of unusual value)? Yes No
If so, indicate below:
Added question and text block

Transfer alleged

Income producing

Encumbrances

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

13. REPRESENTATIVE
PAYEE

No alleged or observed need for payee development/change.

Payee development suggested by:

Selection Date:
T:
CO:
CU:
Name:
Replaced "Repy" with
"Selection Date"

14. FRAUD

No fraud suspected

Fraud suspected before or during interview due to:

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 22 of 26

Rearranged information into charts

VERIFICATION

No reason to doubt negative allegation

CONCLUSION

Total nonexcluded
resource values:

Collateral contacts made:
Name

Liquid
SI

MI

CM
IM
BM
Retro

Type contact/Date
Findings

Nonliquid
SI
MI

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

IM
BM
Retro
Deeming applies

Resources cause
ineligibility:
No

No payee development required
Referred to field office for payee development

Yes

FO payee
development
required.
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

(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

Replaced "Type of
Course" with "Full
time"

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
Split eligible and ineligible

Added space to record more
children both eligible and ineligible.

children into two charts as one

Ineligible Children
Name

Name

Name

requires more information than

SSN

SSN

SSN

following fields: Place of Birth,

DOB

DOB

DOB

Mth
Name
Fth Name

Mth.
Name
Fth Name

Mth.
Name
Fth Name

Evidence
Viewed

Evidence
Viewed

Evidence
Viewed

the other. Removed the
Date of Issue, and Date
Recorded. Replaced "Record
Type, ID#" with "Evidence
Viewed."

Removed "CG DM O"

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

(06-2006) EF (06-2006)

Page 24 of 26

VERIFICATION
None required
Collateral Contact made
Name
Contact type/date

CONCLUSION
Payment effect $

PYMT deficiency
Nonpayment
deficiency

Finding
Evidence Viewed

No discrepancy

None required
Collateral Contact made
Name

Student Status
verified
Replaced "Material

Contact type/date

discrepancy" with "Student

Finding

Status verified"

Evidence Viewed

Removed "None required" block

Numident in file IDN

No discrepancy

Collateral Contact Made

Age Verified

Name

Replaced "Material
discrepancy" with "Age

Contact type/date

Verified"

Finding
Evidence Viewed

Removed need to provide SSNs for children

No discrepancy

Numident in file
Collateral Contact made
Name
Contact type/date

Relationship
verified
Replaced "Material
discrepancy" with

Finding

"Relationship verified"

Evidence Viewed
Moved "Evidence Viewed" from above "Numident in file" to the bottom of the chart.

Form

SSA-8508 BK

(06-2006) EF (06-2006)

Page 25 of 26

REMARKS/DEFICIENCY ANALYSIS

Reviewer's Signature

Form

SSA-8508 BK

Date

(06-2006) EF (06-2006)

Page 26 of 26