TN 18 (05-04)

GN 00301.300 Examples of Completed Evidence Screens

A. Example

Rita Moore, a Title II claimant, reports the receipt of a pension. The FO verifies the amount of the pension with the FBI in a telephone interview.

CLIENT: Rita Moore

CROSS-REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

- AGE - LAWFUL ALIEN STATUS - RELATIONSHIP -IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES -WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE X UNEARNED INCOME

DOCUMENT EVENT DATE: 08142003ISSUANCE/RECORDATION DATE (Y/N): N

IF YES, DATE RECORDED: ________ DATE ISSUED:________

DOCUMENT TYPE: RC LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: XXXXXXXXXX STATE:XX

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): N IF YES, RIN:

COMMENTS: Verified amount of pension with John Thomas, FBI, (555) 555-5555

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): N PAGE: S

B. Example

Rita Moore, a Title II claimant, reports the receipt of a pension and the FO obtains a signed statement from the FBI verifying the amount of the pension.

CLIENT: Rita Moore

CROSS-REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

- AGE - LAWFUL ALIEN STATUS - RELATIONSHIP -IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES -WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE X UNEARNED INCOME

DOCUMENT EVENT DATE: 08142003ISSUANCE/RECORDATION DATE (Y/N): N

IF YES, DATE RECORDED: ________ DATE ISSUED:________

DOCUMENT TYPE: 795 John Thomas (FBI) LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: XXXXXXXXXX STATE:XX

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): N IF YES, RIN:

COMMENTS: Mr. Thomas signed 795 verifying amount of pension

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): N PAGE: S

C. Example

For proof of age and citizenship, claimant/number holder (Rita Moore) submits a birth certificate showing child's name as Reita Koerrs. Claimant's maiden name on the application screen is Rita Korrs. The document is recorded for audit purposes since the name is different.

CLIENT: Rita Moore

CROSS-REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

X AGE - LAWFUL ALIEN STATUS - RELATIONSHIP -IDENTITY

X CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES -WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 04171932 ISSUANCE/RECORDATION DATE (Y/N): Y

IF YES, DATE RECORDED: 04171932 DATE ISSUED:09021973

DOCUMENT TYPE: BC Reita Koerrs LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: Hampton STATE:VA

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): Y IF YES, RIN:0933580-35

COMMENTS:                                       

                                                     

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): N PAGE: S

 

D. Example

Agnes Henderson is filing for RIB benefits. She brings in her 2003 W2 as proof of lag wages. Ms. Henderson works for AART's Office Supply Co. (EIN 32-1870732) in Seattle, WA.

CLIENT: Agnes Henderson

CROSS-REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

- AGE - LAWFUL ALIEN STATUS - RELATIONSHIP - IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES XWAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 12312003 ISSUANCE/RECORDATION DATE (Y/N): X

IF YES, DATE RECORDED: 99999999 DATE ISSUED: 99999999

DOCUMENT TYPE: W2 LANGUAGE:SSSSSSSS

PLACE DOCUMENT CREATED: CITY: Seattle STATE:WA

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): Y IF YES, RIN:32-18170732

COMMENTS: lag wages                             

                                                     

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): X PAGE: S

 

E. Example

Concurrent claims are filed on account #123-00-6789 by the disabled NH, Mary Ann Pharr (maiden name Neer) and child Wayne Pharr; Wayne's DOB is 4 /11/96. The child's birth certificate is presented as proof of age, citizenship and relationship for the child and as proof of age for the NH. Two Evidence Screens must be completed.

NHs Screen

CLIENT: Mary Ann Pharr

CROSS REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

X AGE - LAWFUL ALIEN STATUS - RELATIONSHIP -IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES - WAGES

- DEATH - MARRIAGE - SELF EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 04111996 ISSUANCE/RECORDATION DATE (Y/N): Y

IF YES, DATE RECORDED: 04111996DATE ISSUED: 04301996

DOCUMENT TYPE: CBC-Wayne Pharr LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: SEATTLE STATE:WA COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): Y IF YES, RIN:66432109-86

COMMENTS: N/Hs age at C's birth is 24 yrs.           

MTH Name - Mary Ann Neer                           

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): X PAGE: S

 

CHILD'S Screen

CLIENT: Wayne Pharr

CROSS REFERENCE SSN: 123006789 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

X AGE - LAWFUL ALIEN STATUS X RELATIONSHIP - IDENTITY

X CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES -WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 06151997ISSUANCE/RECORDATION DATE (Y/N): y

IF YES, DATE RECORDED: 04111996 DATE ISSUED:04301996

DOCUMENT TYPE: BC XXXXXXXXXXXXXXXXXXXXXXXXXXX LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: SEATTLE STATE:WA

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): Y IF YES, RIN: 66432109-86

COMMENTS: MTH: Mary Ann Pharr                   

                                                     

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): X PAGE: S

F. Example

Title II aged claimant, Franz Deuringer, submits a family bible with entries written in German as proof of age for a domestic RIB claim. The CR is a certified German translator. The document shows that the claimant was born on 4/3/33. The claimant's DOB allegation on the APPL screen in MCS is 4/2/33. (A personal letter was also presented. A second Evidence Screen can be used to code information concerning the letter.)

CLIENT: Franz Deuringer

CROSS REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 1 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

X AGE - LAWFUL ALIEN STATUS - RELATIONSHIP -IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES - WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 04031933 ISSUANCE/RECORDATION DATE (Y/N): X

IF YES, DATE RECORDED: 999999999 DATE ISSUED: 999999999

DOCUMENT TYPE: BIBLEXXXXXXXXXXXXXXXXXXXXXXXXX LANGUAGE: GERMAN

PLACE DOCUMENT CREATED: CITY: MUNICH STATE: XX

COUNTRY: GE OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): N IF YES, RIN: XXXXXXXXXXXXXXXXXXXXX

COMMENTS:   1 of 2 docs; m-discrep; age proven     

                                                     

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): Y PAGE: S

G. Example

Jonathan C. Grooms, a SSI recipient, reports that he moved on 2/05/2004 and now lives with roommates in an apartment. He verifies rental liability by providing a rent receipt from Reid Management dated 2/28/2004.

CLIENT: Jonathan C. Grooms

CROSS REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 2 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 3 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

- AGE - LAWFUL ALIEN STATUS - RELATIONSHIP - IDENTITY

- CITIZENSHIP X LIVING ARRANGEMENT - RESOURCES -WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 02282004ISSUANCE/RECORDATION DATE (Y/N): X

IF YES, DATE RECORDED: 99999999 DATE ISSUED: 99999999

DOCUMENT TYPE: Rent Recpt-Reid Mgmt LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: Birmingham STATE:AL

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): Y IF YES, RIN: 1005

COMMENTS: Rental liability; pd started 3/1/ 2004.

                                                     

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): X PAGE: S

 

H. Example

Cynthia Pollack files for SSI on 3/7/2004 and alleges owning a checking account with a balance of $500 and a savings account with a balance of $1000. She submits her bank statements from Crestar Bank dated 2/28/2004 as evidence of her resources. Her account number is 32-1675-88. Although her allegation appears to permit eligibility, the FO asks for proof of her resources. The amount is $5000, which makes her ineligible for SSI payments.

CLIENT: Cynthia Pollack

CROSS REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 2 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 2 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

- AGE - LAWFUL ALIEN STATUS - RELATIONSHIP - IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT X RESOURCES -WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 02282004 ISSUANCE/RECORDATION DATE (Y/N): X

IF YES, DATE RECORDED: 99999999 DATE ISSUED: 99999999

DOCUMENT TYPE: BANK STATEMENT-CRESTAR BANK LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: Beaumont STATE:TX

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID(RIN)(Y/N): Y IF YES, RIN: 32-1675-88

COMMENTS: inelig provn; $5000 in savs/savings.               

                                                

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): X PAGE: S

 

I. Example

Marylin Wheeler, a SSI recipient, comes to the FO to submit her pay stubs (dated 3/3/2004 and 3/16/2004) for 3/2004 as proof of her monthly earnings. She reports her earnings on a monthly basis. Ms. Wheeler works for Shannon Moving Co. (EIN 37-8755123) in Boise, Idaho.

CLIENT: Marylin Wheeler

CROSS REFERENCE SSN: 999999999 999999999 999999999

SELECT PROGRAM: 2 1. Title II 2. Title 16 3. Title 18

SELECT TYPE: 3 1. Preclaim 2. Claim 3. Postentitlement

DOCUMENT SUBMITTED AS PROOF OF THE FOLLOWING EVENTS/ISSUES:

- AGE - LAWFUL ALIEN STATUS - RELATIONSHIP - IDENTITY

- CITIZENSHIP - LIVING ARRANGEMENT - RESOURCES X WAGES

- DEATH - MARRIAGE - SELF-EMPLOYMENT - OTHER

- DIVORCE - MILITARY SERVICE - UNEARNED INCOME

DOCUMENT EVENT DATE: 03312004ISSUANCE/RECORDATION DATE (Y/N): X

IF YES, DATE RECORDED: 99999999 DATE ISSUED: 99999999

DOCUMENT TYPE: PAY STUBS - Shannon Moving Co. LANGUAGE: SSSSSSSS

PLACE DOCUMENT CREATED: CITY: Boise STATE:ID

COUNTRY: XX OTHER: XXXXXXXXXXXXXXXXX

RECORD ID (RIN)(Y/N): Y IF YES, RIN: 37-8755123

COMMENTS: Future Monthly Info Stored Locally     

NM: P PPPPPPPPPP POSITION: PPPP OFFICE CODE: PPPP DATE: PPPPPP

ADDITIONAL EVIDENCE (Y/N): X PAGE: S

                                                      


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0200301300
GN 00301.300 - Examples of Completed Evidence Screens - 01/19/2012
Batch run: 01/19/2012
Rev:01/19/2012