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
3rd Party Contact
Centenarian: *

SSN: xxx-xx-

Date letter sent to 3rd party: *
F/u letter sent:
*
1.
2.
3.
4.

Date of interview with 3rd party:
Name of nursing home/facility:
Name of 3rd party:
Title of 3rd party:

*
*
*
*

If the Centenarian is Alive:
1. Date of Birth Correct?
2. Change of facility?
3. Name of new facility:
4. Payee needed?
5. Change of payee needed?
6. Special message posted:
7. Document (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:

YES
YES

NO
NO

YES
YES
YES

NO
NO

*

*
*
YES (mandatory)
*
YES
YES
YES

NO
NO
NO

YES

NO

*$

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 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 21235-6401