Form SSA-8508-BK Supplemental Security Income--Quality Review Case Analys

Form SSA-8508-BK (09-2022)
Discontinue Prior Editions
Social Security Administration

DRAFT

Page 1 of 29
OMB No. 0960-0133

Supplemental Security Income - Quality Review Case Analysis
SSN:

State of Residence:

SM:

ES SSN:

AIPQB:

Case Excluded?

SSA-FO code:

Exclusion code:

SSR Documentation

Yes

No

Field Review Documentation

1. Name of Sampled Individual:

1. Interview Date:

2. Residence Address/Telephone number:

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

3. Mailing Address:
3. MI(s) listed contacted:
Yes
No, Explain
4. Material Individual(s):

None

Payee

Ineligible Spouse

Eligible Spouse

Parent(s)

Spouse of Parent

Ineligible Child

Alien Sponsor/Spouse

Essential Person

4. Address/Telephone entries correct on SSR:
Yes

No (provide correct address)

Residence Address/Telephone number:

5. Name(s) of MI(s):

Mailing Address:

6. Address: Same as SI

Yes

No
5. Others Contacted:

Legal Guardian
Institutional Officer
Interpreter/Assistant

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

9. Last Effective RZ/LI:

8.
(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 case file.

Form SSA-8508-BK (09-2022)

Page 2 of 29

Systems
1. SSN
SI:

SI/MI Interview
Allegation/evidence agrees with SSR
Different or additional SSN/names found

ES:
Evidence viewed:
SS Card
Verified:
2. Age
Citizenship/
Legal Alien Status/
Identity

Medicare Card

Photo Identification

Other

Allegation

SI

ES

Name on Record
Date of Birth:
Date of Birth
SI:
ES:

Place of Birth
Mother:

Mother:

Father:

Father:

Parents Names
BIC
SI:
ES:

AR Code
SI:

Type Evidence

Issuing Agency

Date Recorded
Date/
Place Issued

ES:
Alien Status

U.S. Entry Date

Port of Entry

Country of Origin
Alien Registration. #/
Class Code
Card Expiration Date

Form SSA-8508-BK (09-2022)

Page 3 of 29

Conclusion

Verification

No SSN Discrepancy

SSN verified via SSN card/Medicare card

Multiple SSNs found but
payment not affected

SSN verified via systems query (in file)
Issue Date:

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

Allegation of Age
Accepted

Allegation accepted. Age is not material.
Age verified via numident (IDN code of P is indicated)

Age Verified

Age verified via Title II claim
MBR proof of age :

Does not meet age
requirement

Citizenship/Legal Alien
Status requirement met:

Age Verified - other

Allegation of Citizenship by U.S. birth accepted

U.S. Born

Citizenship/Alien status verified?

Naturalized

Type of verification:

Alien
Refugee
Collateral contact made
Other
Type/date
Does not meet
Citizenship/Alien Status

Place
Name/Title

Findings

Yes

No

Form SSA-8508-BK (09-2022)

Page 4 of 29

Systems
3. Marital Status Code:

SI/MI Interview
Marital History: (including parents of minor child)
Spouse
or
Parents

Name

Spouse Shown:
No

Yes

None

SSN
If SSN is
unknown, provide
DOB/POB/mothers
maiden name

Event

Married
Divorce
Separated
Widowed

Spouse
Parents

Name:

Married
Divorce
Separated
Widowed

Spouse
Parents
Parents Shown:
No

Yes

Date

Married
Divorce
Separated
Widowed

Spouse
Parents

Names:

Married
Divorce
Separated
Widowed

Spouse
Parents

Evidence Viewed:

Contributions from current or prior spouse?

Yes

No

Yes

No

Yes

No

If yes, indicate name of spouse and amount of contribution

Entitlement for benefits from spouse/former spouse?
If yes, indicate Name and SSN, or DOB if SSN is unknown:

Does SI live with an unrelated member of the opposite sex?
If yes, provide the following information:
Name

Alleged Relationship

If disabled, date SI first became disabled.
Note: This may not be the same date as that established on the SSR

Name SSN's/ID info for parents either disabled, deceased or age 62 or over.
If SSN is unknown, provide DOB/POB/Mother's Maiden name
Mother

Father

Form SSA-8508-BK (09-2022)

Page 5 of 29

Conclusion
During review period SI had:

Verification
Allegation agrees with SSR - no reason to doubt

No living with spouse
Documentary evidence viewed
Eligible spouse
Collateral contact made:
Ineligible spouse

No living with parents

Type/date
Place
Name/Title

Eligible parent(s)
Findings
Ineligible parent(s)
Holding out:
Potential T2
Entitlement Referral:
Yes

Established
Not Established

No
See SSA-795s/4178s in file
Other evidence:

Potential Title II entitlement established:

Name
SSN
Type

Form SSA-8508-BK (09-2022)

Page 6 of 29

Systems
4. LA/ISM (Non-Household)

SI/MI Interview
NA

CG

Facility Name/
Address

Federal LA Codes:

Facility
Representative
Name/Title
Type of Contact/Date

State LA Codes:

Date of admission to review period facility:

Did the SI actively participate in the interview?
Yes
No
State/County:

Facility Precedent:
No

Yes

If no, date of release from the review period facility:

Institutional

Non-Institutional Care

Public

Adult foster care

Private - profit

Child foster care

Private - nonprofit

Other

Penal
Medical care
Non-medical care
Publicly operated community residence
Public emergency shelter
Absence/Multiple Residences:
Dates

From

To

Page 7 of 29

Form SSA-8508-BK (09-2022)

Conclusion
Institutional Care
Public medical
Private medical
Substantial Medicaid?
Yes
No
Public or private
educational/vocational/
technical
Publicly operated
community residence
Private nonprofit
residential care
Proprietary for profit
residential care,
educational, or vocational
training facility

Verification
NA
Interview/contact with facility representative established the following:
Institution
SI was institutionalized (Date)
Amount of payment for room and board

$

Other third party source/amount

$

Medicaid

SI's own income

Amount: $

Tax-exempt organization (Church-Key Amendment applies)
Payment excluded:

Yes

No

Non-Institution
SI was in non-institutional care (date):

Public emergency shelter

Facility license number/expiration date

Public correctional/holding
facility

Amount of room and board

$

Other third party source/amount

$

Non-Institutional Care
State living arrangement:

Total Cost:
SI's own income

Amount: $

Foster care agency

Amount: $

Other third party (provide source and amount)
ISM
Other Contact Made
U.S./State residency
requirement:
Met

Type/date

Not Met
Name/Title

LA/ISM deficiency:
Yes

Place

No
Findings

Form SSA-8508-BK (09-2022)

Page 8 of 29

Systems

SI/MI Interview
Household Members

5. LA/ISM
(Household/Transient)

Name

Relationship to SI

PA Income
Type/SSN

Age

CG Entries:
LA 0
(Sharing $

)

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

Federal LA Codes
Rental Liability/Home Ownership
Does SI live alone

State LA Codes

Yes

No

Does SI (or living w/spouse) have home
ownership interest?

Yes
No
Amount of Mortgage: $

Does SI have rental liability?

Yes
No
Amount of Rental Payment: $

Provide the name/address/telephone number
of the landlord

State/County Codes

Is the landlord related to any household
member as a parent or child?

Yes, to whom and how?

No

Does SI live in a residence owned or rented
by a non-resident of SI's household?

Yes (provide name)

No

Name of person in SI's household with rental
liability, if any and amount of payment
J/H Income

SI/ES does not have ownership interest or rental liability:
Is SI a Transient?

Yes

No

Is SI a child living in parents HH?

Yes

No

Is SI in an all PA household?

Yes

No

Does SI purchase/consume food separately?

Yes

No

Yes

No

Amount of Shelter contribution, if any
Does SI contribute towards the total HH
expenses in a sharing arrangement?
Does SI earmark contribution towards the
food and/or shelter expense?

Amount of contribution: $
Yes

No

Food $

Shelter $

SI lives with others and makes no
contribution towards the HH expenses?

Yes

No

Are services required by owner?

Yes

No

Form SSA-8508-BK (09-2022)

Page 9 of 29

SI/MI Household Interviews
Average Household Expenses
Type

Amount ($)

Food

$

Rent

$

Mortgage
(including property insurance)

$

Property Tax (Year/Monthly Amount)

Description of Evidence

$

Heating/Fuel

$

Gas

$

Electricity

$

Water

$

Sewer

$

Garbage removal

$

Total

$

Above averages are for:
If SI or living with spouse has ownership interest or rental liability, what is the amount of contributions
from other HH members, if any:
$
Does SI receive contributions from outside the HH?

Yes

No

If yes, provide the following:
Name/Address/Telephone of person that SI is receiving contributions from
(SSA-795 in file)

Does SI receive a housing subsidy?

Yes

No

If so, what is the source of the subsidy?
What is the amount of the subsidy, if known?

What is the length of time at the review period residence?

Last date SI/ES was out of the U.S.

Temporary absence by SI or any HH member

Unknown

Amount

Form SSA-8508-BK (09-2022)

Page 10 of 29

SI/MI Household Interviews
Has the SI resided at the current residence address for the entire review period?
If not, complete the applicable living arrangement changes below:

Changes in household composition in review period:

Changes in household expenses in review period:

Changes in LA in review period:

Yes

No

Form SSA-8508-BK (09-2022)

Page 11 of 29

Conclusion
Basis for Federal LA
Home ownership:
Title
Life Estate
Unprobated estate
Trust
Rental Liability:
Rent: $
CMRV: $
Flat Fee: $
Room Rental
Commercial establishment
Non-commercial
PA household

Verification
LA/ISM/Residency established during interview with SI/other household members
Collateral sources contacted
Name/Telephone Number
Date
Type of Contact
Findings
SSA-795 in file pertaining to HH expenses
Bills/Receipts of HH expenses were requested for the past 12 months, but were not available
Bills/Receipts were available for
QRA Determination

Separate consumption
Separate purchase

Number of HH members

Sharing

Total HH expenses

Earmarked sharing
food/shelter

SI's pro-rata share
SI's contribution

Transient
Intervening A
VTR applies

Other HH member's
contribution
Inside ISM (including VRT)
Outside ISM

Child who lives in
household with parent, and
who is not subject to VTR
Basis for State LA:

LA/ISM for:
Review Period
Month
CM

Inside ISM:
$

IM

Outside ISM:
$

BM

U.S./State Residency
Requirement:
Met

Last Date SI/ES outside U.S.
Not Met

LA/ISM deficiency:
No

Yes

Living Arrangement

ISM $

Form SSA-8508-BK (09-2022)

Page 12 of 29

Systems
6. Unearned Income
Title XVI
SI:
Fed:
State:
CM:
IM:
BM:
Retro:
MI:
CM:
IM:
BM:
Retro:
Title II
SI:
CM:
IM:

SI/MI Interview
Note: Only BM allegations need be shown if no income changes are alleged for review period.
SI's Allegation
Title XVI
Title II
VA Pension
VA Compensation
Railroad Retirement
Government Pension
Black Lung
State Disability Payments
Foster Care
Energy Assistance
Unemployment Compensation
Workers Compensation
Sick Pay
Education Assistance
Dividends/Royals
Rental Income
Interest
Gifts
Loans
Support from absent parent
Other Cash Support
Gambling Income
Miscellaneous

CM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

MI's Allegation
Title XVI
Title II
VA Pension
VA Compensation
Railroad Retirement
Government Pension
Black Lung
State Disability Payments
Foster Care
Energy Assistance
Unemployment Compensation
Workers Compensation
Sick Pay
Education Assistance
Dividends/Royals
Rental Income
Interest
Gifts
Loans
Support from absent parent
Other Cash Support
Gambling Income
Miscellaneous

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

IM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

BM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

BM:
Retro:
MI:
CM:
IM:
BM:
Retro:
Other
SI:
CM:
IM:
BM:
Retro:
MI:
CM:
IM:
BM:
Retro:

Evidence Viewed:
1099 ALERT:

Title XVI Recoup:

CM

IM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

BM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Form SSA-8508-BK (09-2022)

Page 13 of 29

Conclusion
Unearned income did not
cause an error in the
sampled payment
The following unearned
income amount caused a
payment error:

Verification
FINDINGS
Title XVI

Title II

RRB

Black Lung

VA

OPM

Verified by SSR - no reason to doubt

Verified by award letter or other evidence in SI's possession
Collateral contact made:

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

Name/Title/Organization
Income/Income
Exclusion established
Amounts

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

IM: $

BM: $

Type/Date
Name/Title/Organization
Income/Income
Exclusion established
Amounts
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 of Child
Source of Income
Type of Income
Verified by
Deeming applies

Amounts

CM: $

Excluded court ordered support payments made by ineligible spouse/parent
Unstated income suspected/confirmed:

Form SSA-8508-BK (09-2022)

Page 14 of 29

Systems

SI/MI Interview

7. Work History Earned Income Last date of employment: SI:
Employment history for 3 years ending with sample month:
Military:
Sampled Individual
Total quarters from SER:

MI:

Employer Name/Address or Self-Employment

Dates

Year last worked from SER:

1099 Alert:

Material Individual
Employer Name/Address or Self-Employment

Dates

SSR Wages:
SI:
CM:
IM:

Review Period earnings:

BM:
MI:
CM:
IM:
BM:
SEI:

Earned Income exclusions?

None

Work expenses of BWE

IRWE

PASS

Cafeteria Plan

Student child earned income

Court Ordered Payments
Type
Amount
Frequency
Source
Employment history prior to last 3 years
Employer Name/Address or Self-Employment

Dates

Earned Income Exclusions:

Does the SI have a Union membership?

Yes (union ID)

No

Does the SI have Military Service?

Yes (dates of service)

No

Does the SI have a pending claim/prior denial
for benefits based on work/military service?

Yes (explain)

No

Form SSA-8508-BK (09-2022)

Page 15 of 29

Conclusion
No potential entitlement to
other benefits

Verification
Potential entitlement not suggested by SI/MI's allegations, no reason to doubt
Potential entitlement suggested:
Title II/VA - made referral to file

Potential entitlement
established for:

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

No earned income in the
review period
Review period earnings no payment error

Source
Type
Date

Earned income caused
payment error:
$
No earned income
exclusions apply

CM: $

Findings

IM: $

BM: $

No earned income alleged, no reason to doubt
Earned income established:
See employer contact in file
See summary of SI/MI's records

Following earned income
exclusions apply:

See SSA-795
See summary/copy of other business record in file
Gross wages:
CM

$

IM

$

BM

$

Net Earnings from Self-Employment
Amount

$

Year
Deeming applies
Earned Income Exclusions Established:
Type
Amount/Frequency
Established by
Ineligible Child with Earnings
Name
Amount
Verified by

CM: $

IM: $

BM: $

Form SSA-8508-BK (09-2022)

Page 16 of 29

Systems
8. Liquid Resources

SI/MI Interview
Allegations
Patient Account

Yes

No

Yes

No

Direct Deposit
BCR:

Checking Account

Yes

No

Yes

No

Savings Account

Yes

No

Yes

No

BCA:

Credit Union
Other Bank Accounts
(Christmas club, etc.)
CD

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Savings Bonds

Yes

No

Yes

No

Promissory Notes

Yes

No

Yes

No

Stocks/Bonds

Yes

No

Yes

No

Mutual Funds

Yes

No

Yes

No

Prepaid Burial Plan

Yes

No

Yes

No

Safe Deposit

Yes

No

Yes

No

Trusts
401(k) Plans/Keough
Accounts
LI Dividend Accumulations

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Name:

1099 Alert:

CG Entries
RE01

SV

RE04

CK

RE08

CD

RE21

Svgs Bds

SI

Cash on hand

RE

CM: $

CM: $

IM: $

IM: $

BM: $

BM: $

Positive Allegation Information:
Account Type/
Financial Institution
Account Number

SSI Direct Deposit

MI

Balances ($)

Owner Name
SI

MI

SI

MI

SI

MI

SI

MI

T2 Direct Deposit

Check Cashing Location,
if no Direct Deposit alleged
If SI/MI do not have SSN, provide
the Tax ID Number (TID)
Is SI/MI's name on anyone else's
bank account? If so, provide name
Prior accounts in the last 24 months?

Yes

Place where funds are kept for burial

NA

No (if yes, show FI name and location):

Other financial institutions used to transact
business i.e., personal loans, mortgages
Deposits made by joint owner?

Yes

No (if yes, provide Name/Date/Amount):

Form SSA-8508-BK (09-2022)

Page 17 of 29

Conclusion

Verification

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

Findings
Account Type/
Account Number

Financial
Institution

Owner
Name

CM
IM
BM
Yes
No
Interest
If yes, see element 6
CM
IM
BM
Yes
No
Interest
If yes, see element 6
CM
IM
BM
Yes
No
Interest
If yes, see element 6
CM
IM
BM
Yes
No
Interest
If yes, see element 6
CM
IM
BM
Yes
No
Interest
If yes, see element 6
CM
IM
BM
Yes
No
Interest
If yes, see element 6
CM
IM
BM
Yes
No
Interest
If yes, see element 6

Liquid resources caused or
contributed to ineligibility for
the sampled payment

Total countable liquid
resources on first day of
sample month:
SI

Balances

MI

Checking:

Savings:

Other:
Total:

Geo Search did not identify additional accounts
Other Liquid Resource Findings
Type

Balances
CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

CM: $

IM: $

BM: $

Form SSA-8508-BK (09-2022)

Page 18 of 29

Systems
9. Real Property

SI/MI Interview
Allegation of real property ownership by SI/MI:
Home Property Ownership

RE Field Entries

Home Property Type:
Non-farm
Farm

Yes

No

Trailer/Mobile home

Ownership
SI is sole owner (non-life estate)

MI is sole owner (non-life estate)

Jointly owned with spouse

Jointly owned with relative (non-spouse)

Jointly owned with non-relative

Life estate

Unprobated estate

Other (equitable ownership, remainder
interest, etc.)

Non-Home Property Ownership Interest:
Type

CG Entries

Other

Yes

No

Owner

Loan Alleged

CMV

Farmland (rented)

$

$

Farmland (used by SI)

$

$

Commercial
(non-farm) or
residential property,
rented

$

$

Non-Excluded previous
or second residence
(not rented)

$

$

Unimproved land, idle

$

$

Foreign property

$

$

Other (mineral, timer,
water rights,
easements, etc.)

$

$

Unknown (type cannot
be determined)

$

$

Evidence of
Ownership/Value

$

$

Burial Plot/Crypt/
Location/Value
Designated for

$

$

Transfer of property since 12/14/1999?
Yes
No

If transfer of ownership alleged, provide the
following: Type of real property/Name and
address of recipient of property/date of transfer/
Reason for the transfer/monetary or other
compensation received.
(Document on SSA-795)

Attempt to Dispose of Property?

Yes

No

Income producing Property?

Yes

No

Form SSA-8508-BK (09-2022)

Page 19 of 29

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

Verification
Allegations Verified by Government Records:
Alpha listing Contact method:

Personal Visit

Letter

Telephone

Date of Contact
Name of Contact

SI/MI owns non-excluded
real property valued at:
$

Title of Contact

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

No property ownership found

Ownership Discovered

Owner

Owner

Location

Location

CMV
(duration of
ownership)

CMV
(duration of
ownership)

Other Collateral contact made
Type Contact/Date

Findings

Internet

Form SSA-8508-BK (09-2022)

Page 20 of 29

Systems
10. Vehicles

SI/MI Interview
Positive allegation

None alleged

RE Field Data

CG Entries

Year/Make

Year/Make

Model

Model

Condition

Condition

Owner

Owner

Use

Use

VIN

VIN

License Number

License Number

Transfer Alleged

Yes

No

Transfer Alleged

Evidence Viewed

Evidence Viewed

Encumbrances

Encumbrances

Year/Make

Year/Make

Model

Model

Condition

Condition

Owner

Owner

Use

Use

VIN

VIN

License Number

License Number

Transfer Alleged

Yes

No

Transfer Alleged

Evidence Viewed

Evidence Viewed

Encumbrances

Encumbrances

Yes

No

Yes

No

Form SSA-8508-BK (09-2022)

Page 21 of 29

Conclusion
No vehicle ownership
by SI/MI
Vehicle exclusion applies:

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

Transportation
Vehicle #1

$

Vehicle #2

$

Vehicle #3

$

Vehicle #4

$

Employment
Other
Total vehicle value:
$
Non-excluded value
$

See SSA-795 regarding vehicle use
Collateral contact made:
Name
Type/Contact/Date

Findings

Form SSA-8508-BK (09-2022)

Page 22 of 29

Systems
11. Life Insurance
RE Field Data

SI/MI Interview
Positive allegation

None alleged

Insurance Company
Name

Insurance Company
Name

Policy Number
Issue Date

Policy Number
Issue Date

Owner

Owner

Face Value

$

Face Value

$

Cash Value

$

Cash Value

$

Yes

Outstanding Loans?

CG Entries

No

Outstanding Loans?

Age at Issue

Age at Issue

Premium
amount/frequency

Premium
amount/frequency

Type of Policy

Type of Policy

Yes

No

Fully paid Policy?

Yes

No

Fully paid Policy?

Yes

No

Policy Viewed?

Yes

No

Policy Viewed?

Yes

No

Does policy produce
Dividend additions or
div accumulations

Yes

No

Does policy produce
Dividend additions or
div accumulations

Yes

No

Transfer alleged

Yes

No

Transfer alleged

Yes

No

Accelerated life
insurance payments?

Yes

No

Accelerated life
insurance payments?

Yes

No

Yes

No

Insurance Company
Name

Insurance Company
Name

Policy Number
Issue Date

Policy Number
Issue Date

Owner

Owner

Face Value

$

Face Value

$

Cash Value

$

Cash Value

$

Outstanding Loans?

Yes

No

Outstanding Loans?

Age at Issue

Age at Issue

Premium
amount/frequency

Premium
amount/frequency

Type of Policy

Type of Policy

Fully paid Policy?

Yes

No

Fully paid Policy?

Yes

No

Policy Viewed?

Yes

No

Policy Viewed?

Yes

No

Does policy produce
Dividend additions or
div accumulations

Yes

No

Does policy produce
Dividend additions or
div accumulations

Yes

No

Transfer alleged

Yes

No

Transfer alleged

Yes

No

Accelerated life
insurance payments?

Yes

No

Accelerated life
insurance payments?

Yes

No

Form SSA-8508-BK (09-2022)

Page 23 of 29

Conclusion
No life insurance
ownership by SI/MI

Verification
No Reason to doubt negative allegations
Collateral contact made

Dividend accum.
value

Company Name

Company Name

Face value does not
exceed $1500 per
insured individual

Policy Number

Policy Number

Owner Name

Owner Name

Total CSV is
SI

MI

CM
IM
BM
Retro

Total Face
Value

$

Total Face
Value
CM

Face value does not
exceed $1500 per
insured individual
Countable CSV value
of life insurance
SI
CM
IM
BM
Retro
CSV dividends set
aside for burial

MI

IM

$

BM

Total CSV

Total CSV

Company Name

Company Name

Policy Number

Policy Number

Owner Name

Owner Name

Total Face
Value

$

Total Face
Value
CM

IM

Total CSV

BM

CM

IM

BM

CM

IM

BM

$

Total CSV

CSV/Dividends set aside for burial (See SSA-4169/SSA-795 in file)
Dividends paid?

Ownership
Pertinent Values
Dividend
Accumulation values

Yes

No

(if yes, see Element 6)

Form SSA-8508-BK (09-2022)

Page 24 of 29

Systems
12. Resources Summary/Other
Non-liquid Resources

SI/MI Interview
Does SI own other non-liquid resources, (items of unusual value)?
If so, indicate below:

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

13. Representative Payee
Selection Date:

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

T:
CO:
CU:
Name:

14. Fraud

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

Yes

No

Form SSA-8508-BK (09-2022)

Page 25 of 29

Conclusion
Total non-excluded
resource values:
Liquid
SI

Verification
No reason to doubt negative allegation
Collateral contacts made:

MI

CM
IM
BM
Retro

Name
Type contact/Date
Non-Liquid
SI
MI

CM
IM
BM
Retro

Findings

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

Deeming applies
Resources cause ineligibility:
No

Yes

FO payee development
required

No payee development required

No development required

Referred to field office for payee development
Name
Type contact/Date

Findings

No fraud suspected

No development required

Fraud referral made

Fraud referred due to:

Form SSA-8508-BK (09-2022)

Page 26 of 29

Supplemental Documentation
15. Death of MI
DH
Name
Relationship to SI
Date of Death
Evidence viewed

16. Student Status
Student Name

Student Name

School Name

School Name

School Address

School Address

Dates of Attendance

Dates of Attendance
Yes

Full time

No

Evidence viewed

17. Age

Yes

Full time
Evidence viewed

Evidence presented by SI/MI, or derived from collateral contact

Eligible Children
Name

Name

Name

SSN

SSN

SSN

DOB

DOB

DOB

Name

Name

Name

SSN

SSN

SSN

DOB

DOB

DOB

Mother's
Name
Father's
Name
Evidence
Viewed

Mother's
Name
Father's
Name
Evidence
Viewed

Mother's
Name
Father's
Name
Evidence
Viewed

Ineligible Children

18. Relationship
Ineligible child of SI

Birth record (see above/page 2)

Ineligible sibling of SI

Marriage record

Parent to eligible child

Name:

Spouse as parent to eligible child

Date:

Alien sponsor to spouse/dependents

Issued by:

Other

Place:

No

Form SSA-8508-BK (09-2022)

Page 27 of 29

Conclusion
Payment effect
$

Verification
None required
Collateral contact made

Payment deficiency

Name

Non-payment deficiency

Contact type/date
Finding
Evidence viewed

No discrepancy

None required

Student status verified

Collateral contact made
Name
Contact type/date
Finding
Evidence viewed

No discrepancy

Numident in file IDN

Age verified

Collateral contact made
Name
Contact type/date
Finding
Evidence viewed

No discrepancy

Numident in file

Relationship verified

Collateral contact made
Name
Contact type/date
Finding
Evidence viewed

Form SSA-8508-BK (09-2022)

Page 28 of 29

Remarks/Deficiency Analysis

Reviewer's Signature:

Date:

Form SSA-8508-BK (09-2022)

Page 29 of 29

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1611(c)(1), and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and
timely decision on any claim filed.
We will use the information to make a determination on eligibility for benefits. We may also share this information for the purposes,
called routine uses:
• To specified Federal and State agencies to prepare information for verification of benefit eligibility under section 1631(e)
of the Social Security Act; and
• To a contractor for the purpose of collating, evaluating, analyzing, aggregating or otherwise refining records in this
system when Social Security Administration contracts with a private firm.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0040, entitled Quality
Review System, as published in the Federal Register (FR) on October 13, 1982, at 47 FR 45606, and 60-0103, entitled
Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 11, 2006, at
71 FR 1830. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 (OMB) control number. We estimate that it will take about 30 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.