Date of this Report
Claimant: NYSIF Case#: -Unit - D/A:
Agency Name: NWI Investigative Group, Inc. Investigation Date:
Person who conducted investigation: Title: Investigator
Agency Investigation No.: NYSIF Investigation No.:
Phone Field By Appointment Preliminary report #: Final report
Note different special instructions such as speak with 2 neighborhood sources and then approach the beneficiary unannounced, make an appointment with the beneficiary to ensure she is seen, but speak to 2 neighbors prior to the appointment or interview 3 neighborhood sources and do not contact the beneficiary.
Remarriage checks are field visits to three (3) properly identified and verifiable adult sources, not of the same household or family. One (1) of these sources may be the beneficiary, AFTER the other 2 sources have been interviewed.
1. Was beneficiary personally observed?
If yes, provide description:
Height
Weight
Race
Eye color
Hair color
Gender
Distinguishing marks
Comment on mobility
2. If interviewed, did beneficiary present proper photo identification?
If yes, ID type
Number
If no, what type of non-photo ID did beneficiary present?
ID type
Number
3. Has address and/or phone number of record changed?
If yes, provide new address and/or new phone #
4. Has the beneficiary remarried or have plans to remarry in the next 6 months? Note: Beneficiary
must notify NYSIF immediately if they remarry.
If yes, explain
5. Were surroundings /circumstances consistent to response to #4 above? (Photo of possible spouse on wall, etc)
If no, explain
6. Did beneficiary (if remarried) provide a copy of the marriage certificate?
If no, obtain name, address and phone number where marriage certificate can be secured
7. Are there dependent children?
If yes, provide the following information:
Name
SS#
Date of Birth
8. Is dependent attending school?
If yes, provide the following information:
Name, address and phone number of school
9. Is beneficiary currently undergoing medical treatment?
If yes, list names and addresses of medical providers
10. Is there a Power of Attorney?
If yes, provide details
11. Are checks being received in a timely manner?
If no, explain
12. Secure a signed and dated form DP523B or Spousal Questionnaire from the beneficiary
13. Is beneficiary deceased?
If yes, provide details
14. Did informant (if beneficiary deceased) provide a copy of death certificate?
If no, obtain name, address and phone number where death certificate can be secured
15. Were 3 sources interviewed?
If yes, complete source 1,2,3 below, provide name and address (include apt. no.). If name refused, provide description. Indicate what each source said about beneficiary’s marital status, who beneficiary resides with, existence of significant other and possibility beneficiary will remarry in the future.
If no, explain and complete all sources that were interviewed
Source 1
Source 2
Source 3
16. Important evidence and indicators
17. Follow up undertaken/suggested
Report text:
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Approved by: William J. Donnelly
Rev 10/13
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