SSA-8508 Current Version

Form Approved
OMB No. 0960-0133

SUPPLEMENTAL SECURITY INCOME - QUALITY REVIEW CASE ANALYSIS
1. SSN
2. Type of Review:
APQB/S0

ES SSN
Stewardship
State of Residence

SM
Other
SSA-FO Code

IDA

SSR DOCUMENTATION

FIELD REVIEW DOCUMENTATION

1. Name of Sampled Individual:

1. Interview date:

2. Residence Address:

2. SI's Existence Verified By:
Direct Observation
Other, Explain

Mailing Address:
3. Mls Listed Contacted:
Yes
No, Explain

3. Telephone:
4. Material Individual(s):
Payee
Ineligible Spouse
Eligible Spouse
Parent(s)
Spouse of Parent
Ineligible Child
Alien Sponsor/Spouse
Essential Person

None

4. Address/Telephone Entries
Correct on SSR:
Yes
No, Correct:
5. Others Contacted:
Legal Guardian
Institutional Officer
Interpreter/Assistant

5. Name(s) of MI(s):
6. Address: Same as Sl

Yes

No

7. Limited Review Indicators:
None
Goldberg/Kelly
Death
No Payment in Sample Period
Sampled Checks Returned Timely
Address Change Outside Review Area
Special Deeming
Other
8. Federal Budget Month:
9. State Budget Month

6.

Death Precluded Interview:
Date of Death

7. Federal Budget Month:
8. State Budget Month:

9.

(Stewardship Review Only) CFR not requested
as the only deficiency is beneficiary 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.

10.Case Excluded:Code
Reason for exclusion:

10.Last effective RZ date:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 1 of 26

SSR-CFR
1. SSN

SI/Ml INTERVIEW
Allegation/evidence agrees with SSR

SI

Different or additional SSN/names found

ES
Verified:
CF/SSR Discrep.
(see remarks)

Evidence viewed:
SS card
Medicare card
Other
Reason no SSN issued prior to age 18; (if applicable)

2. AGE
CITIZENSHIP/
LEGAL ALIEN
STATUS/IDENTITY

Sl

Photo Ident.

ES
Name on Record
Date of Birth

Date of Birth

Birthplace

SI:

Parents

ES:
Type Evidence
Issuing Agency
BIC

Date Recorded

SI:

Date/Place Issued

ES:

Alien Status
U.S. Entry Date
Port of Entry

AR CODE

Country of Origin

SI:

Alien Reg. #/
Class Code

ES:

SSR/CFR Discrp.
(see Remarks)
Form SSA-8508 BK (10-1993)

Card Exp. Date

Allegation only
EF (10-2000)

Evidence viewed
Page 2 of 26

VERIFICATION

CONCLUSION

SSN verified via SS card/Medicare card

No SSN
discrepancy

SSN verified via systems query (in-file).
Issue date

Multiple SSNs
found but payment not
affected

SSN obtained after age 18 - special development completed.

Allegation accepted. Age is not material.
Age verified via numident (IDN code of P is indicated)
Age verified via Title II claim.
MBR proof of age code
Allegation of citizenship by U.S. birth accepted.
Documentary evidence viewed.

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

No material
age discrepancy
Citizenship/
Legal Alien
Status requirement met:
U.S. born
Naturalized
Alien

Collateral contact made:

Refugee

Type/date:

Other

Place:
Name/title:

Material
discrepancy
found

Finding:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 3 of 26

SSR-CFR

SI/Ml INTERVIEW

3. MARITAL STATUS
CODE:

Marital History: (including parents of minor child)
Name

No

Date

Yes
2.

Name:
Parents Shown:
SI:

Event

1.

Spouse Shown:
SI:

SSN

No

3.
Yes

Name:
Evidence Viewed:
Type:
Names

Event date:
Issue Date:
Issuing Agency:
Contributions from current or prior spouse:

Entitlement for benefits from spouse/former spouse:

SI lives with unrelated member of the opposite sex:
Name:
Alleged relationship:

SSR/CFR Discrp.
(see remarks)

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 4 of 26

VERIFICATION

Allegation agrees with SSR - no reason to doubt.

Documentary evidence viewed.

CONCLUSION

During review
period Sl had:
No living
with spouse
Eligible
spouse

Collateral contact made:
Type/date:

Ineligible
spouse

Place:
Name/title:

No living
with parents

Finding:

Eligible
parent(s)

Holding out:

Established
Not established

See SSA-795s/4178s in file
See other evidence:

Ineligible
parent(s)
Material
discrepancy
found:

Potential Title II entitlement established:
Name:
SSN:
Type:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 5 of 26

SSR-CFR

4. LA/ISM
(Non Household)
CG

SI/MI INTERVIEW

Facility (Name/Location)

Facility Representative (Name/Title)

FEDERAL LA
CODES

Type of Contact/Date
Did SI actively participate in interviews?
Yes

STATE LA CODES

No

Date of admission to review period facility
Date of release from review period facility
Last date SI/ES was out of U.S.

STATE/COUNTY

Number of residences over last 3 years
NONINSTITUTIONAL CARE

INSTITUTIONAL

Facility
Precedent:
No

Yes

Public

Adult foster care

Private - profit

Child foster care

Private - nonprofit

Other

Penal
Medical care
Nonmedical care
Publicly operated
community residence
Public emergency
shelter

Absence/Multiple Residences:
From

To

From

To

From

To

SSR/CFR Discrp.
(see remarks)

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 6 of 26

VERIFICATION

CONCLUSION

SI interview/contact with facility representative established the following:
SI was institutionalized (date)
Size/number of residents
Total monthly cost
Amount of pmt for room/board
Medicaid

Substantial Medicaid?
Yes
No

SI's own income.

Amount

Tax-exempt organization (Church-Key Amendment applies)
Other third party:
Source
Amount
Payment excluded:

INSTITUTIONAL CARE
Public medical
Private medical

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

Yes

No

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

Sl was in noninstitutional care (date)
Placement by
Supervised by
License number and expiration date

Public emergency
shelter
Public correctional/
holding facility
(NO2)
NONINSTITUTIONAL
CARE

Total cost:
Amount of pymt for room and board
Source of payment:
SI's own income.

Amount

Foster care agency.

Amount

State living
arrangement:
ISM
U.S./State residency
requirement:

Other third party
Source
Amount

Met

Not Met

LA/ISM deficiency:
Yes
No

Other Contact Made
Type/date
Name/title
Place
Finding

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 7 of 26

SSR-CFR

SI/MI INTERVIEW

5. LA/ISM
(Household/
Transient)

Household Members

Pertinent CG
Entries:
LA 0
(Sharing $

Relationship
to SI

Name

Age

PA Income
Type

)

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

State LA Codes

SI living alone
Sl (or living with spouse) has home ownership interest/rental liability
Mortgage amount $
Rent Amt. $
Sl lives in a residence owned or rented by a non-resident of SI's household
Person in Sl's household with rental liability, if any
Amount:
Landlord/rental agency name, address, telephone number

State/County Codes
Landlord related to any household member?
Yes
No
If so, how/to whom?
J/H Income

If SI/ES does not have ownership interest or rental liability:
Sl is a transient
Sl is a child living in parent's HH
Sl is in an all-assistance HH
Sl purchases/consumes food separately
Amount of shelter contribution, if any:
Sl contributes toward total HH expenses in a sharing arrangement:
Amount $
SI earmarks contribution toward food and/or shelter expenses:
Amount (food) $
Amount (shelter) $
Sl lives with others and makes no contribution toward HH expenses
Services required by owner

SSR/CFR Discrp.
(see remarks)
Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 8 of 26

SI/Ml HOUSEHOLD INTERVIEWS
Average Household Expenses
TYPE

AMOUNT

Food

$

Rent

$

Property Tax

$

Mortgage (include
property insur.)

$

Heating/Fuel

DESCRIPTION OF EVIDENCE

$

Gas

$

Electricity

$

Water

$

Sewer

$

Garbage removal

$

TOTAL

$

Above averages are for

through the month before the sample month

Household member(s) not contacted because

If Sl or living with spouse has ownership interest or rental liability, amount of contribution(s) from other household
member(s), if any: $
Amount of food/shelter contributions from outside HH:

$

Name and address of contributor:

Housing subsidy
No
Yes
Amount of subsidy (if known): $

Unknown

Length of time at review period residence
Number of residences during last 3 years
Last date SI/ES was out of U.S.
ISM is a loan (see SSA-795 in file)
Amount of cash contributions and loans of ISM $
Temporary absence by Sl or any household member:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 9 of 26

SI/MI HOUSEHOLD INTERVIEWS
Changes in living arrangements including household composition/expenses in review period:

Changes in household composition in review period

None

Changes in household expenses in review period

None

Changes in LA in review period

None

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 10 of 26

VERIFICATION

CONCLUSION

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

Transient

Collateral sources contacted:
(Name, date, type of contact, findings)
LA/ISM Established

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

AVERAGE HOUSEHOLD EXPENSES
Amount

Description
of Evidence

Type
Food
Mortgage/Rent
Property Tax
Property Ins.
Heating/Fuel
Gas
Electricity
Water
Sewer
Garbage Removal
TOTAL

$
$
$
$
$
$
$
$
$
$
$

Basis for LA

Above averages are for
the sample month

Home ownership:
Title
Life estate
Unprobated estate
Trust
Rental liability
Rent
$
CMRV $
Flat fee $
Room rental
Commercial
establishment
Non-commercial
Rent-free

through the month before

HUD subsidy
PA household
Separate consumption
Separate purchase

Number of household members:
Total household expenses
$
SI's pro rata share
$
SI's contribution
Other household member's contribution
Inside ISM (including VTR)
Outside ISM

Sharing
Earmarked sharing
food/shelter
VTR applies
Intervening A

LA/ISM FOR:
CM

LA

ISM $

IM

LA

ISM $

BM

LA

ISM $

Last date SI/ES outside U.S.

State living arrangement basis:
Inside ISM:
$
Outside ISM:
$
State supp. errors
U.S./State residency
requirement
Met
Not Met
LA/ISM deficiency:
No

Form SSA-8508 BK (10-1993)

EF (10-2000)

Yes

Page 11 of 26

SSR-CFR
6. UNEARNED
INCOME
Title XVI
SI:

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

SI's Allegations
(IM)
(BM)

Title II
CM
IM
BM
Retro

MI:
CM
IM
BM
Retro

CM
IM
BM
Retro

MI's Allegations
(IM)
(BM)

Support from
Absent Parent
Other Cash Supp.
Gambling Income
Miscellaneous

Other
SI:

(CM)

Title XVI
Title II
Interest
Bank Deposits
VA Pension
VA Compensation
Govmt. Pension
Private Pension
Railroad Retir.
Black Lung
Assistance Based
on Need
Educational
Assistance
State Disb. Pymt
Foster Care
Energy Assist.
Unemply. Comp.
Worker's Comp.
Sick Pay
Dividends/Royal.
Rental Income
Gifts
Loans

CM
IM
BM
Retro

MI:
CM
IM
BM
Retro

SI:

Income Type

EVIDENCE:

MI:
CM
IM
BM
Retro
1099 ALERT
Title XVI Recoup

SSR/CFR Discrp.
(see remarks)

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 12 of 26

VERIFICATION
Title XVI
VA

Title II
OPM

RRB

CONCLUSION
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
Place
Name/Title
Income/Income exclusion established

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

Type/Date
Place
Name/Title
Income/Income exclusion established

Excluded court ordered support payments made by ineligible spouse/parent

Unearned income
exclusion applies
to SI/ES's budget
month income:

Interest income, see Element 8.
CM

IM

BM

Ineligible child with unearned income:
Name/type:
CM

IM

BM

Verified by:

Unstated income suspected/confirmed:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Deeming applies

Page 13 of 26

SSR-CFR
7. WORK HISTORY
EARNED INCOME

SI/Ml INTERVIEW
Last date of employment: Sl
MI
Employment history for 3 yrs. ending with sample month:
Type of Work
Employer
Dates

Employee

Military:

Total quarters
from SER:
Year last
worked from
SER:

Review Period earnings:

1099 Alert:

SI:

Evidence:

SSR Wages:

CM
IM
BM
Retro: Y
MI:
CM
IM
BM
Retro: Y

Earned Income exclusions:
Work expenses of BI
N

IRWE

Student child earned income

PASS
N

None

Type

Amount

Frequency

Source

SEI:

Employment history prior to last 3 years:

Earned Income
Exclusions:

Union membership
Military service
Pending claim/prior denial for benefits based on work/military service
Additional information to facilitate collateral contacts

Federal tax return filed:

Yes

No

Amount of refund $
SSR/CFR Discrp.
(see remarks)

Form SSA-8508 BK (10-1993)

Copy available:

Yes

No

Person who filed return

EF (10-2000)

Page 14 of 26

VERIFICATION

CONCLUSION

Potential entitlement not suggested by Sl/Ml's allegations, no reason to doubt.
Potential entitlement suggested:
Title II/VA - made referral to file

No potential
entitlement to
other benefits
Potential
entitlement
established for:

Collateral contact below - made referral to file
Ruled out by development in file

No earned
income in the
review period

Collateral contact made:
Source:
Date/type:
Finding:

Review period
earnings - no
payment error

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

The following
earned income
caused payment
error: $

See employer contact in file.
See summary of Sl/Ml's records.
See SSA-795

No earned income
exclusions apply

See summary/copy of tax return.
See summary/copy of other business record in file.
Gross wages:
CM

IM

BM

Following
earned income
exclusions apply:

NE/SE amount/period
Earned income exclusions established:
Type:
Amount/frequency:
Established by:
Ineligible child with earnings:
Deeming applies

Name
Amount: CM

IM

BM

Verified by:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 15 of 26

SSR-CFR
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
Type of Resource
Checking Account
Savings Account
CD
Other Bank Account
(Christmas club, etc.)
Prepaid Burial Plan
Patient Account
Savings Bonds
Promissory Notes
Stocks/Bonds
Mutual Funds
Credit Union
Safe Deposit
Miscellaneous
401 (K) Plans/Keough Accts.
Trusts
Cash on Hand: $
Life Insurance Dividend Accumulations

Allegations

SI

MI

Positive Allegation Information:
Type:
Institution:
Owner(s):
ID:
Date/Balance:
Encumbrances:
Is your name on anyone else's bank acct?
Deposits by joint owner:

No

Yes

No

Yes

Amount of joint owner deposit(s) $
Dates made:
No accounts alleged
Check cashing location
Familiar/nearby financial inst.
Credit card, mortgage, pers. loan from
Prior accounts at
Place where utility bills are paid
Place where money orders are purchased
Place where funds are kept for burial

SSR/CFR Discrp.
(see remarks)

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 16 of 26

VERIFICATION

CONCLUSION

SI has been in an institution/non institutional care facility for at least 3 years - no
reason to doubt negative allegation.
Collateral contact made (Include patient account)
Type/date:
1. Address:
Finding:

Inst. Name:

No Account
Account ID
Owner(s)
Balances
CM $
Interest

Account type
IM $
No

Type/date:
2. Address:
Finding:

BM $
Yes, see Element 6

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

Liquid resources
caused or contributed to
ineligibility for
the sampled pymt

Inst. Name:

No Account
Account ID
Owner(s)
Balances
CM $
Interest

Account type
IM $
No

Type/date:
3. Address:
Finding:

BM $
Yes, see Element 6

Inst. Name:

No Account
Account ID
Owner(s)
Balances
CM $
Interest

IM $
No

SI

MI

Checking:
Savings:

Account type

Type/date:
4. Address:
Finding:

Total countable
liquid resources
on first day of
sample month:

BM $

Other:

Yes, see Element 6
Inst. Name:
Total:

No Account
Account ID
Owner(s)
Balances
CM $
Interest

Account type
IM $
No

BM $
Yes, see Element 6

No reason to
doubt negative
allegation

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 17 of 26

SSR-CFR

SI/MI INTERVIEW

9. REAL PROPERTY
Allegation of real property ownership by SI/MI:
None
RE Field Entries

Ownership interest:

Home property
Type:

SI is sole owner (non-life estate)
MI is sole owner (non-life estate)

Non-farm

Jointly owned with spouse

Farm

Jointly owned with relative (non-spouse)

Trailer/Mobile home

Jointly owned with non-relative

Other

Life-estate
Unprobated estate
Other (equitable ownership, remainder interest, etc.)
Unknown

CG Entries

Nonhome property
Type

Owner

Value

Farmland (rented)
Farmland (used by SI/MI)
Commercial (non-farm) or residential property, rented
Commercial property (non-farm) used by Sl or MI
Unexcluded previous or second residence (not rented)
Unimproved land, idle
Foreign property
Other (mineral, timber, water rights, easements, etc.)
Unknown (type cannot be determined)
Evidence of ownership/value

CMV:
Encumbrances
Burial plot/crypt
Location/Number
Designated for:
Transfer of property
To:
Reason:
Compensation:

SSR/CFR Discrp.
(see remarks)

Date:

Attempt to dispose of property:
Income producing property:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 18 of 26

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

Allegations verified by government records:

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

Alpha listing (personal visit, phone call, or letter)
Date of contact
Name of contact

SI/MI owns
nonexcluded real
property valued
at:
$

Title of contact

Finding:
No property ownership
Home ownership
Nonhome (including burial plot) ownership

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

Nonhome (including non-excluded burial plot) ownership

Owner
Location
CMV

(duration of ownership interest)

Owner
Location
CMV

(duration of ownership interest)

Other collateral contact made:
Type contact/date
Finding

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 19 of 26

SI/MI INTERVIEW

SSR-CFR
10. VEHICLES

RE Field Data

CG Entries

RE 1

None alleged
Positive allegation

1

2

3

Yr/Make:
Model/Body:
Condition:
Owner:
Use:
VIN:
License #:
Transfer alleged
Evidence viewed:

Title

Regist.

Other

Additional information to verify value/use/ownership
SSR/CFR Discp.
(see Remarks)

Handicapped equipped

Encumbrances

Duration of ownership:

11. LIFE
INSURANCE

RE Field Data

CG Entries

None alleged
Positive
allegation
Insurance Co.
Policy Number
Owner
Insured
Face Value
Cash Value
Outstanding
Loan
Age at Issue
Issue Date
Prem. Amt./Frq
Type of Policy

Policy Vwd
Inf. Allgd
Particip.
Fully paid insurance policy?
Yes

Policy Vwd
Inf. Allgd
Particip.
No

Policy Vwd
Inf. Allgd
Particip.

If the policy is not paid up, what is the premium amount and frequency of payment?
Amount $

Frequency

If yes, does supplemental contract exist?

Yes

No

Does the policy produce dividend additions or dividend accumulations?
Yes
No
Unknown
SSR/CFR Discrp.
(see remarks)

Form SSA-8508 BK (10-1993)

Transfer alleged
Accelerated life insurance payments

EF (10-2000)

Page 20 of 26

VERIFICATION

CONCLUSION

No reason to doubt negative allegations.
N.A.D.A. value(s):

No vehicle ownership by Sl/Ml

Encumbrances

Vehicle exclusion
applies:
Value under
limit
Medical
Employment
Specially
equipped
Other

See SSA-795 regarding vehicle use.
Collateral contact made

Total vehicle value
$

Name
Type contact/date

Nonexcluded value
$

Finding:

No reason to doubt negative allegations

No life insurance
ownshp by SI/Ml

Collateral contact made
Company

Policy

CM

Owner

IM

BM

Total face value:
Total CSV:
CSV/dividends set aside for burial (see SSA-4169/SSA-795 in file)

Dividends paid

No

Ownership
Pertinent values
Dividend accumulation values

Yes (see Element 6)

Dividend accum.
value
Face value does
not exceed $1500
per insur. indiv.
Total CSV is
SI
CM
IM
BM
Retro

MI

Face value
exceeds
$1,500
per insured.
Countable CSV
value of life ins
SI
MI
CM
IM
BM
Retro
CSV dividends
set aside for burial

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 21 of 26

SSR-CFR
12. RESOURCES
SUMMARY/OTHER
NONLIQUID
RESOURCES

SI/MI INTERVIEW
No household goods/personal effects of unusual value alleged.
Description of item(s) of unusual value:

Evidence:

Transfer alleged
Income producing
Encumbrances
SI/Ml alleges following resource(s) are to be used for burial expenses:

SSR/CFR Discrp.
(see remarks)

13. REPRESENTATIVE
PAYEE
Repy:
T:
CO:
CU:
Name:

14.FRAUD

No alleged or observed need for payee development/change.
Payee development suggested by:

No fraud suspected
Fraud suspected before or during interview due to:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 22 of 26

VERIFICATION
No reason to doubt negative allegation

CONCLUSION
Total nonexcluded
resource values:

Collateral contacts made:
Name:

CM
IM
BM
Retro

Type contact/date:
Finding:

CM
IM
BM
Retro

SI

Liquid

MI

Nonliquid
SI
MI

Deeming applies

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

Resources cause
ineligibility:
No

No payee development required
Referred to field office for payee development

Yes

FO payee
development
required.

Name
Type contact/date
Finding: (explain above)

No development
required.

No development required

No fraud
suspected

Fraud referred due to:

Form SSA-8508 BK (10-1993)

Fraud
referral made

EF (10-2000)

Page 23 of 26

SUPPLEMENTAL DOCUMENTATION
15. DEATH OF MI
DH:

Name
Relationship to SI
Date of death
Evidence viewed

16. STUDENT STATUS

17. AGE
Eligible Children
(not SI)
Ineligible Children

CG
DM 0

STUDENT NAME
School Name
School Address
Dates of Attendance
Type of Course
Evidence Viewed
STUDENT NAME
School Name
School Address
Dates of Attendance
Type of Course
Evidence Viewed
FULL TIME ATTENDANCE

Yes

No

Evidence presented by SI/Ml, or derived from collateral contact
Name
Date of Birth
Place of Birth
Record Type, ID #
Issuing Agency
Date of Issue
Date Recorded
Mother's Name
Father's Name
SSN
Name
Date of Birth
Place of Birth
Record Type, ID #
Issuing Agency
Date of Issue
Date Recorded
Mother's Name
Father's Name
SSN

18. RELATIONSHIP
Ineligible child of Sl

Birth record (see above/pg. 2)

Ineligible sibling of SI
Parent to eligible child
Spouse as parent to eligible child

Marriage record
Name
Date
Issued by

Place

Alien sponsor to spouse/dependents
Other
Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 24 of 26

VERIFICATION
None required

CONCLUSION
Payment effect $

Collateral contact made
Name
Contact type/date
Finding:
Evidence viewed:

Pymt deficiency

None required

No discrepancy

Collateral contact made
Name
Contact type/date
Finding:

Material
discrepancy

Nonpayment
deficiency

Evidence viewed (see page 24)

No discrepancy

None required
Numident in file

IDN

Material
discrepancy

Collateral contact made
Name
Contact type/date
Finding:

Evidence viewed (see page 24)
SSNs for children

Evidence viewed

No discrepancy

Numident in file

Material
discrepancy

Collateral contact made
Name
Contact type/date
Finding:

Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 25 of 26

REMARKS/DEFICIENCY ANALYSIS

Reviewer's Signature

Date

Attach All Reports of Contact, Available Documentation, Payment and Other Related Worksheets, and Continuation
Pages.
Form SSA-8508 BK (10-1993)

EF (10-2000)

Page 26 of 26