Medicare Non-utilization Project (MNUP)

Form Approved
OMB No. 0960-0780

SOCIAL SECURITY ADMINISTRATION

Development Worksheet
Telephone 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.

Date of Interview:
Date of Birth correct?
Address correct?
Payee needed?
Change of Payee needed?
Special Message posted:
ID question(s) used to establish identity:

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

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 control number. We estimate that it
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