Medicare Non-utilization Project (MNUP)

Form Approved
OMB No. 0960-0780

SOCIAL SECURITY ADMINISTRATION

Development Worksheet
Face-to-Face Interview
Individual: *
Advanced Telephone Call Date: *
Letter sent: *
F/U letter sent: *

SSN: xxx-xx-

If the Individual is Alive:
1.
2.
3.
4.
5.
6.
7.

Face to Face date:
o Location of interview:

*

Date of Birth correct?
Change of Address needed?
Payee needed?
Change of Payee needed?
Special Message posted:
REMARKS:

YES
YES
YES
YES
YES

NO
NO
NO
NO

If the Individual is Deceased:
1.
2.
3.
4.
5.
6.
7.

Date of Death (mm/dd/yyyy):
Proof of Death type:
Proof of Death posted to EVID?
Date of Termination action:
Was a payee involved?
Possible FRAUD involved?
OIG referral?
If no OIG referral, explain in REMARKS

8.

Estimated amount of overpayment:

9. Special Message posted:
10. REMARKS:

YES (mandatory)
YES
YES
YES
$
YES

NO
NO
NO

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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
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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