I-1-3-91.Exhibit — Office of the Inspector General (OIG), Allegation Management and Fugitive Enforcement Division - Response Attachment

OIG, ALLEGATION MANAGEMENT AND FUGITIVE ENFORCEMENT DIVISION - RESPONSE ATTACHMENT

From:

(Allegation No.):

PLEASE CHECK THE APPROPRIATE RESPONSE

Allegation unsubstantiated [ ]

Allegation substantiated/corrective action taken [ ]

Allegation partially substantiated/corrective action taken [ ]

No SSA violation [ ]

Referred to OIG, Office of Investigations [ ]

Monetary Disposition

Amount of overpayment:

Amount of recovered funds:

Other:

Prepared by:                                                              Date: