Centenarian Project Development Worksheets: Face-to-Face Interview; Telephone Interview; Third Party Contact; Unable to Locate

Form Approved
OMB No. 0960-XXXX

SOCIAL SECURITY ADMINISTRATION

Centenarian Development Worksheet
Telephone Interview
Centenarian: *
Advanced Telephone Call Date: *
Date letter sent: *
F/u letter sent: *
If the Centenarian is Alive:
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:

If the Centenarian is Deceased:
1. Date of Death (mm/dd/yyyy):
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 in REMARKS
8. Estimated amount of overpayment:
9. Special Message posted:
10. REMARKS:

SSN: xxx-xx-

*
YES
YES
YES
YES
YES

NO
NO
NO
NO

*
*
YES (mandatory)
*
YES
YES
YES
*$
YES

NO
NO
NO

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