Social Security Administration |
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Form Approveed |
OMB No. 0960-0189
RSI/DI QUALITY REVIEW CASE ANALYSIS – SAMPLED NUMBER HOLDER |
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NOTE TO REVIEWER: In opening the interview, explain that this case is one of a small number selected by chance for review and that the purpose of this review is to find out how well the Social Security program is working. Tell them that the review consists of asking questions about their entitlement to Social Security benefits and that we may need to talk to others who have information about their entitlement. If necessary, point out that the Social Security Administration is authorized by law to review from time to time the entitlement of beneficiaries.
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. The beneficiary is not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 30 minutes to read the instructions, gather the necessary facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
I. IDENTIFYING AND REVIEW INFORMATION
A. SIC: |
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B. NH’s SSN: |
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C. Sample Selection Date (As Shown on SCL): |
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D. Review Amount on SCL: $ |
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E. Review Amount Determined by QR: $ |
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F. |
Explanation of SCL
Changes, if Any: |
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G. NH’s Name (As Shown on MBR): |
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H. NH’s Address/Phone |
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Address: |
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Phone: |
( ) |
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I. Payee Name Address/Phone |
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Name: |
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Address: |
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Phone: |
( ) |
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NH Under FRA and Entitled to RIB in Closed Year (Complete SSA-4281/SSA-4659) |
II. NUMBER HOLDER
A. Identity
Type of Interview |
Face-to-Face |
Telephone |
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B. Other Names and SSNs Shown in Claims Folder/Numident
1. Other Names: |
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2. Other SSNs: |
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C. Date of Birth/Citizenship |
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1. Date of Birth and Proof Code on MBR Printout: |
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2. Place of Birth: |
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3. MN: |
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FN: |
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4. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien |
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5. Evidenc
/Documentation in Claims
Folder/MCS Screens: |
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6. Evidence Needing
Verificatio
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7. Date of Birth
Established by Desk Review:
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8. Citizenship/Alien
Status Established by
esk Review:
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Remarks: |
II. NUMBER HOLDER |
Consolidated Review |
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A. Identity |
A. Identity |
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1. Existence Verified by: |
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Observation |
Photo ID |
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Other: |
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2. SSN Verified by: |
SSN Card |
Medicare Card |
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Other: |
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B. Other Names and SSN’s Used |
B. Other Names/SSN’s |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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C. Date of Birth and Citizenship/Alien Status |
C. DOB and Citizenship/Alien |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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Evidence Obtained in Field Review:
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II. NUMBER HOLDER |
D. Application
1. Benefit Type: |
RIB DIB |
If DIB, Established Onset Date: |
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2. Date Claim Filed: |
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3. DOE (and MOEL Option Code if RIB): |
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4. DOE Determined by Desk Review: |
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Remarks: |
E. Multiple Entitlement Involved
YES (Complete Below) |
NO |
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1. Claim Number on Non-sampled SSN: |
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2. Scope of Review on Non-sampled SSN: |
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Full Review Limited Review Not in Scope of Review |
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F. Other Claims Activity |
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1. Did the NH ever file for any other benefits (including SSI)? |
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YES (Explain) |
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NO |
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2. Does the NH have any eligible children who have not filed for benefits? |
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YES (Explain) |
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NO |
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3. Unadjudicated Claims Issues: |
NONE APPLY |
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Unprocessed Application |
Deemed Filing |
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Protective Filing |
Open Application |
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Partial Adjudication |
Potential Entitlement (Leads) |
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Delayed Claim |
Misinformation |
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(Explain)
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II. NUMBER HOLDER |
Consolidated Review |
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D. Application |
D. Application |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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E. Multiple Entitlement |
E. Multiple Entitlement |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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F. Other Claims Activity |
F. Other Claims Activity |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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II. NUMBER HOLDER |
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G. Underpayment on Sampled SSN Needed to Be Addressed |
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YES (Explain) |
NO |
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H. Recovery of Overpayment in Sample Month |
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YES (Explain) |
NO |
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I. SMI Determination |
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NOT APPLICABLE |
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The SMI determination, including the premium deduction and penalty amounts (if any), is correct. |
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YES |
NO (Explain) |
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J. Payment Amount |
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1. Amount of CMA/SM Check: $ |
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, Period: |
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2. Payment Cycle Indicator (CYI): |
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3. Payment Combined with Other Benefit: YES NO |
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4. Check Amount Affected by Other Withholding (e.g., Medicare C/D Premiums, Voluntary Tax Withholding, Garnishment, Treasury Offset Program, etc.): |
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YES (Explain) |
NO |
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II. NUMBER HOLDER |
Consolidated Review |
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G. Underpayment |
G. Underpayment |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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H. Recovery of Overpayment in Sample Month |
H. Overpayment |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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I. SMI Determination |
I. SMI Determination |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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J. Payment Amount |
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J. Payment Amount |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain) |
II. NUMBER HOLDER |
NUMBER HOLDER NEVER MARRIED |
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K. Marital History of Sampled Number Holder |
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1. Current/Last Marriage to: |
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a. Age/Date of Birth: |
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b. SSN: |
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c. Date of Marriage: |
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d. Type: |
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e. Place of Marriage: |
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f. How Terminated: |
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g. Date Terminated: |
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h. Place Terminated: |
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i.
Evidence/Documentation in Claims Folder/MCS Screens: |
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j. Evidence Needing
Verification: |
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2. Prior Marriage to: |
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a. Age/Date of Birth: |
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b. SSN: |
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c. Date of Marriage: |
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d. Type: |
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e. Place of Marriage: |
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f. How Terminated: |
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g. Date Terminated: |
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h. Place Terminated: |
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i.
Evidence/Documentation in Claims Folder/MCS Screens: |
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j. Evidence Needing
Verification: |
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3. Prior Marriage to: |
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a. Age/Date of Birth: |
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b. SSN: |
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c. Date of Marriage: |
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d. Type: |
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e. Place of Marriage: |
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f. How Terminated: |
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g. Date Terminated: |
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h. Place Terminated: |
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i.
Evidence/Documentation in Claims Folder/MCS Screens: |
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j. Evidence Needing
Verification:
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II. NUMBER HOLDER |
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K. Marital History of Sampled Number Holder |
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Number Holder Agrees With Marital History in DR Summary |
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Number Holder Disagrees With DR Summary: (Complete Below) |
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1. Current/Last Marriage to: |
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a. Age/Date of Birth: |
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b. SSN: |
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c. Date of Marriage: |
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d. Type: |
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e. Place of Marriage: |
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f. How Terminated: |
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g. Date Terminated: |
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h. Place Terminated: |
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i. Evidence Obtained: |
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2. Prior Marriage to: |
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a. Age/Date of Birth |
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b. SSN: |
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c. Date of Marriage: |
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d. Type: |
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e. Place of Marriage: |
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f. How Terminated: |
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g. Date Terminated: |
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h. Place Terminated: |
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i. Evidence Obtained: |
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3. Prior Marriage to: |
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a. Age/Date of Birth: |
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b. SSN: |
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c. Date of Marriage: |
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d. Type: |
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e. Place of Marriage: |
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f. How Terminated: |
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g. Date Terminated: |
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h. Place Terminated |
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i. Evidence Obtained: |
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Consolidated Review: |
II. NUMBER HOLDER |
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L. Computation Information |
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1. Work Issues |
Explanation |
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Wages |
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Self-Employment |
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Lag Wages/SEI |
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Gaps |
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Annual Reports |
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Other |
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2. Military Service |
NONE |
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a. Branch of Service: |
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b. Serial Number: |
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c. Dates of Active Military Duty After September 7, 1939: |
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From |
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To |
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ALG/PRV/PRE |
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From |
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To |
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ALG/PRV/PRE |
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d. If MS prior to 1957, NH Receives/Eligible for Military/Civilian Federal Pension? YES NO |
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e.
Evidence/Documentation in Claims Folder/MCS Screens: |
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f. Evidence Needing
Verification: |
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3. Railroad Employment |
NONE |
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a. Number of Service Months on Earnings Record: |
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b. Were 5 or more years of railroad work alleged? |
YES NO |
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4. Prior Period of Disability |
NONE |
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a. PPD Shown on MBR: |
Date of Onset: |
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Term Date: |
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b. Documentation in File: |
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c. PPD Established by Desk Review: |
Date of Onset: |
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Term Date: |
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II. NUMBER HOLDER |
Consolidated Review |
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L. Computation Information |
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L. Computation Information |
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1. Work Issues |
1. Work Issues |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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Year |
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Amount on E/R |
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Amount Alleged |
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Evidence Obtained in Field Review: |
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2. Military Service |
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2. Military Service |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain) |
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Evidence Obtained in Field Review: |
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3. Railroad Employment |
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3. RR Employment |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain) |
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4. Prior Period of Disability |
4. Prior Period(s) of Disability |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain) |
II. NUMBER HOLDER |
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L. Computation Information |
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5. Windfall Elimination Provision |
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COMPLETE IF NUMBER HOLDER BORN JANUARY 2, 1924 OR LATER |
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a. NH has 30 or More Special Minimum Coverage Years. |
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YES (Go to II.M.) |
NO |
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b. NH is Entitled to a Foreign or Domestic Pension, or Lump Sum in Lieu of a Monthly |
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Periodic Pension, Based on Work After 1956 Not Covered by Social Security. |
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YES |
NO (Go to II.M.) |
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(1) Date of First Eligibility to Pension (Month/Year): |
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(2) Date of First Entitlement to Pension (Month/Year): |
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(If either date is prior to 1986, go to 5.d.) |
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(3) Other Exception to WEP Applies: |
YES |
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NO |
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(If Yes, go to 5.d.) |
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c. Information About the Pension |
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(1) Agency or Organization from Which the Pension Is Received: |
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Name: |
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Address: |
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(2) Period(s) of Employment Upon Which the Pension Is Based (Include Both |
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Employment Covered and Not Covered by Social Security): |
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From (Month, Year): |
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To (Month, Year): |
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From (Month, Year): |
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To (Month, Year): |
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(3) Period(s) of Employment After 1956 Not Covered by Social Security That Is Used to |
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Determine the Pension: |
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From (Month, Year): |
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To (Month, Year): |
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From (Month, Year): |
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To (Month, Year): |
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(4) Amount of the Pension for the First Month the Claimant is Concurrently Entitled to the |
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Pension and the Social Security Benefit: |
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Monthly Amount: $ |
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(Obtain proof if guarantee applies.) |
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d.
Evidence/Documentation in Claims Folder/MCS Screens: |
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e. Evidence Needing
Verification: |
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II. NUMBER HOLDER |
Consolidated Review |
L. Computation Information |
L. Computation Information. |
5. Windfall Elimination Provision |
5. WEP |
Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain)
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Evidence Obtained in Field Review:
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II. NUMBER HOLDER |
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M. Current DIB Entitlement |
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NOT APPLICABLE (Go to II.N.) |
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1. Period(s) of Disability |
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a. Current Established Onset Date: |
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b. Date of Entitlement: |
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c. Prior Period of DIB: YES (Complete Below) NO |
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Effect on Current Entitlement: Waiting Period Comps Medicare Other |
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2. Disability-Related Work Information |
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a. Earnings After Current Established Onset Date: YES (Complete Below) NO |
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b. Disability-Related Work Issues |
Explanation |
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Trial Work Period |
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Substantial Gainful Activity |
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Unsuccessful Work Attempt |
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Cessation |
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Extended Period of Eligibility |
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Termination |
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Expedited Reinstatement |
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Other |
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c.
Evidence/Documentation in File: |
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d. Evidence Needing
Verification: |
II. NUMBER HOLDER |
Consolidated Review |
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M. Current DIB Entitlement |
M. Current DIB Entitlement |
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1. Period(s) of Disability |
1. Period(s) of Disability |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain) |
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2. Disability-Related Work Information |
2. Disability-Related Work Info |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary |
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(Explain)
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Evidence Obtained in Field Review: |
II. NUMBER HOLDER |
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3. Worker’s Compensation/Public Disability Benefit (WC/PDB) |
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a. NH Filed for WC/PDB: YES NO (Go to II.M.4) |
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b. Status of Claim: Awarded (Complete Below) Denied Pending |
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c. Employer Name and Address |
Payer Name and Address |
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d. Describe Type of
Payments Received: |
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e. WC/PDB Affects Review Period Payment: YES NO |
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(Explain) |
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f. Documentation in
Claims Folder/MCS Screens: |
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g. Evidence Needing
Verification: |
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4. Child-Care Dropout (Less than 3 Regular Drop-Out Yrs): YES NO (Go to II.N) |
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a. Child Under Age 3 Lived With NH During a Year That NH Had No Earnings: |
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YES NO |
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b. Documentation in
Claims Folder/MCS Screens:
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c. Evidence Needing
Verification: |
II. NUMBER HOLDER |
Consolidated Review |
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3. Worker’s Compensation/Public Disability Benefit (WC/PDB) |
3. WC/PDB |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain) |
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Evidence Obtained in Field Review: |
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4. Child-Care Dropout Years |
4. Child-Care Dropout |
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Number Holder Agrees With DR Summary |
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Number Holder Disagrees With DR Summary: |
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(Explain) |
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Evidence Obtained in Field Review: |
II. NUMBER HOLDER |
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N. Fugitive Felon |
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a. Are there any unsatisfied felony warrants for NH’s arrest or for violations of probation/parole? |
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YES NO (Go to II.O) |
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b.
Evidence/Documentation in Claims Folder/MCS Screens: |
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c. Evidence Needing
Verification: |
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O. Criminal Activities |
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NH Not Involved in Any Criminal Activities Listed Below |
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Removal (formerly Deportation) |
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Subversive Activities |
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Offenses Against the National |
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Confined for a Criminal Offense |
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Security (Hiss Act) |
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Disability Determination Based on a Condition That Occurred During the Commission of a |
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Felony After October 19, 1980 |
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Disability Determination Based on a Condition That Occurred During Confinement for a Felony |
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Conviction |
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Evidence/Documentation
in Claims Folder/MCS Screens: |
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Evidence Needing
Verification: |
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P. Representative payee |
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Does the claims folder indicate an unresolved representative payee issue (need for payee change, |
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etc.) for the sampled number holder? |
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YES (Explain) NO |
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II. NUMBER HOLDER |
Consolidated Review |
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N. Fugitive Felon |
N. Fugitive Felon |
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NH states/desk review summary shows that there are no unsatisfied felony warrants for arrest or for violations of probation/parole. |
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YES |
NO (Explain) |
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Evidence Obtained in Field Review: |
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O. Criminal Activities |
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O. Criminal Activities |
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If any of the criminal activities listed in II.O. of the desk |
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review summary are involved, discuss and resolve below. |
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P. Representative Payee |
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P. Representative Payee |
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There is an indication that an unresolved representative |
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payee issue exists (need for payee change, etc.) for the sampled number holder. |
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YES (Explain) |
NO |
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II. NUMBER HOLDER |
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Q. Consolidated Review Summary |
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Desk and field review findings are in agreement. |
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Desk and field review findings are not in agreement. Indicate the section(s) where the |
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disagreement exists. |
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Section A |
Section B |
Section C |
Section D |
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Section E |
Section F |
Section G |
Section H |
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Section I |
Section J |
Section K |
Section L |
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Section M |
Section N |
Section O |
Section P |
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Additional Development/Findings/Remarks: |
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Signature of Reviewer(s) |
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Date: |
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Desk Reviewer |
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Date: |
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Field Reviewer |
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Date: |
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Consolidated Reviewer |
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Form SSA-2930-BK (xx-xxxx)
Destroy All Prior Editions |
Page |
File Type | application/msword |
File Title | RSI/DI QUALITY REVIEW CASE ANALYSIS – SAMPLED NUMBER HOLDER |
Author | 144543 |
Last Modified By | 889123 |
File Modified | 2011-10-20 |
File Created | 2011-10-20 |