Form SSA-2931 RSI/DI Quality Review Case Analysis - Auxiliaries/Surviv

Form Approved
OMB No. 0960-0189

SOCIAL SECURITY ADMINISTRATION

RSI/DI QUALITY REVIEW CASE ANALYSIS - AUXILIARIES/SURVIVORS
NOTE TO REVIEWER: In opening the interview, ask if the beneficiaries received an appointment letter. If the letter was not received, show the beneficiaries a copy of the letter. Explain that
this case is one of a small number collected by chance for review, and that the purpose of this review is to find out how well the social security program is working. Stress that this case was
not selected because there was any question about it. Tell them that the review consists of asking questions about their entitlement to social security benefits and that we need to talk to
others who have information about their entitlement. If necessary, point out that the Social Security Administration is authorized by law to review form time to time the entitlement of
beneficiaries.

See Revised PRA, Attached

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction
Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number.
TIME IT TAKES TO COMPLETE THIS FORM: We estimate that it will take you about 30 minutes to complete this form. This includes the time it will take to read the instructions, gather the
necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations
Bldg., Baltimore, MD 21235-0001. Send only comments relating to our "time it takes" estimate to the office listed above. All requests for Social Security cards and other claims-related
information should be sent to you local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of you telephone directory.

I. IDENTIFYING AND REVIEW INFORMATION
A. SIC:

B. NH's SSN:

C. Sample Selection Date (As Shown on SCL):
D. Review Amount on SCL: $
E. SSI Offset Involved in Determining the Sample Dollars

YES

NO

F. Review Amount Determined by QR: $
G. Explanation of SCL, Changes, if Any:

H. NH's Name (As Shown on MBR):
I. Beneficiaries in Scope of Review
1. BIC

2. Name/Address/Phone

3. Payee Name/Address/Phone

Name:

Name:

Address:

Address:

Phone:

(

)

Phone:

Name:

Name:

Address:

Address:

Phone:

(

)

Phone:

Name:

Name:

Address:

Address:

Phone:

(

)

Phone:

(

)

(

)

(

)

Additional Beneficiaries Shown in Remarks (Page 30)
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II. DECEASED/NONSAMPLED NUMBER HOLDER
A. Number Holder Information
Deceased Number Holder

Nonsampled Number Holder

B. Other Names and Corresponding SSN's Shown in Claims Folder/Numident
1. Other Names:
2. Other SSNs:
C. Date of Birth/Citizenship

NOT APPLICABLE

1. Date of Birth and Proof Code on MBR Printout:
2. Place of Birth:
(a) Alien Status:

Yes

No

3. MN:

(b) If yes, develop per QRM-3766
FN:

4. Evidence/Documentation in Claims Folder/MCS Screens:

5. Evidence Needing Verification:

6. Date of Birth Established by Desk Review:
D. Date of Death

NOT APPLICABLE

1. Date of Death on MBR:
2. Place of Death:
3. Evidence/Documentation in Claims Folder/MCS Screens:

4. Evidence Needing Verification:
5. Date of Death Established by Desk Review:
6. If the LSDP is in the scope of review, was it correctly paid?
YES

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NO (Explain)

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FIELD/TELEPHONE REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER

Consolidated Review

A. Number Holder Information
Deceased NH

A. Number Holder Information
Nonsampled NH
B. Other Names/SSN's

B. Other Names and SSN's Used in Reporting Earnings
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

C. Date of Birth

NOT APPLICABLE

C. Date of Birth

Beneficiary Agrees With DR Summary:
Beneficiary Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

D. Date of Death/LSDP

NOT APPLICABLE

D. Date of Death/LDSP

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)

Evidence Obtained in Field Review

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II. DECEASED/NONSAMPLED NUMBER HOLDER

NUMBER HOLDER NEVER MARRIED

E. Marital History of Number Holder
1. Current/Last Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

2. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

3. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

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FIELD/TELEPHONE REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER
E. Marital History of Number Holder
Beneficiary Agrees With Marital History in DR Summary
Beneficiary Disagrees With DR Summary: (Complete Below)
1. Current/Last Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
2. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
3. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:

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II. DECEASED/NONSAMPLED NUMBER HOLDER
F. Computation Information
1. Work Issues

Explanation

Wages
Self-Employment
Lag Wages/SEI
Gaps
Incomplete Postings
Duplicate/Erroneous Postings
Annual Reports
None Apply
2. Military Service

NONE

a. Branch of Service:

b. Serial Number:

c. Dates of Active Military Duty After September 7, 1939:
From
From

To
To

ALG/PRV/PRE
ALG/PRV/PRE

d. NH Receives or is Eligible for Military/Civilian Federal Pension
YES

NO

e. Evidence/Documentation in Claims Folder /MCS Screens:
f. Evidence Needing Verification:
3. Railroad Employment

NONE

a. Number of Service Months on Earnings Record:
b. Were 7 or more years of railroad work alleged?
YES

NO

4. Prior Period(s) of Disability

NONE

a. Date DIB Application Filed:
b. Latest EOD:

Termination Date:

c. Prior EOD:

Termination Date:

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FIELD/TELEPHONE REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER
F. Computation Information

Consolidated Review
F. Computation info.

1. Work Issues

1. Work Issues

Beneficiary Agrees With DR Summary

Beneficiary Disagrees With DR Summary:
(Complete Below and Obtain an SSA-795)
Year

Amount on E/R

Amount Alleged

2. Military Service

2. Military Service

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

3. Railroad Employment

3. RR Employment

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
4. Prior Period(s) of Disability

4. Prior Period(s) of Disability

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

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III.

SPOUSE/SURVIVING SPOUSE

NOT APPLICABLE

A. Identity
1. Name:

2. SSN (BOAN)

B. Other Names and Corresponding SSN's Shown in Claims Folder/Numident
1. Other Names:
2. Other SSNs:

C. Application
1. Date Claim Filed:
2. DOE and MOEL Option Code:
3. Was the beneficiary previously entitled to benefits (including SSI) on this or any other SSN?
YES (Explain)

NO

4. Unresolved Claims Issues:

NONE APPLY

Unprocessed Application

Deemed Filing

Protective Filing

Open Application

Partial Adjudication

Potential Entitlement (Leads)

Delayed Claim

Totalization

Explain:

5. Month Of Entitlement Determined by Desk Review:

D. Multiple Entitlement Involved
YES (Complete Below)

NO

1. Claim Number on Nonsampled SSN:
2. Scope of Review of Non sampled SSN:
Limited Review

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Full Review
Not in Scope of Review

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III.

SPOUSE/SURVIVING SPOUSE

NOT APPLICABLE

A. Identity

Consolidated Review
A. Identity

1. Existence Verified by:
Observation
2. SSN Verified by:

Other:
SS Card

Medicare Card

Other:

B. Other Names and SSN's Used in Reporting Earnings

B. Other Names/SSN's

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

C. Application

C. Application

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

D. Multiple Entitlement Involved

D. Multiple Entitlement

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

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III.

SPOUSE/SURVIVING SPOUSE
E. Recovery of Prior Overpayment in Sample Month/Review Period
YES (Complete Below)

NO

Total Amount of Overpayment: $
F. Prior Underpayment on Sampled SSN Which Needed to Be Addressed
YES (Explain)

NO

G. Payment Amount(s)
1. Amount of PMA Check: $
2. Amount of CMA/SM Check:

, for Period:
$

, for Period:

3. Payment Combined with Other Benefit
YES

NO

H. Date of Birth/Citizenship

NOT APPLICABLE

1. Date of Birth and Proof Code on MBR Printout:
2. Place of Birth:
(a) Alien Status:

Yes

No

3. MN:

(b) If yes, develop per QRM-3766
FN:

4. Evidence/Documentation in Claims Folder/MCS Screens:

5. Evidence Needing Verification:
6. Date of Birth Established by Desk Review:
Remarks:

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FIELD/TELEPHONE REVIEW
III.

SPOUSE/SURVIVING SPOUSE

Consolidated Review
E. Recovery of
Overpayment in SM/Review
Period

E. Recovery of O/P in SM/Review Period
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

F. Prior U/P on Sampled SSN

F. Underpayment on Sampled SSN
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

G. Payment Amount(s)

G. Payment Amount(s)

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)

H. Date of Birth

NOT APPLICABLE

H. Date of Birth

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)

Evidence Obtained in Field Review:

Development/Findings/Remarks:

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DESK REVIEW
III.

SPOUSE/SURVIVING SPOUSE
I. Marital History of Spouse/Surviving Spouse
1. Current/Last Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

2. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

3. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

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FIELD/TELEPHONE REVIEW
III.

SPOUSE/SURVIVING SPOUSE
I. Marital History of Spouse/Surviving Spouse
Beneficiary Agrees With Marital History in DR Summary
Beneficiary Disagrees With DR Summary: (Complete Below)
1. Current/Last Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
2. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
3. Prior Marriage to:
a. Age/Date of Birth:

b. SSN:

c. Date of Marriage:

d. Type:

e. Place of Marriage:
f. How Terminated:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:

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III.

SPOUSE/SURVIVING SPOUSE
J. Government Pension Offset
COMPLETE FOR SPOUSES, DIVORCED SPOUSES, SURVIVING SPOUSES, OR SURVIVING DIVORCED
SPOUSES ENTITLED OR APPLYING FOR BENEFITS IN OR AFTER DECEMBER 1977.
1. Spouse/Divorced Spouse/Surviving Spouse/Surviving Divorced Spouse Is Eligible For Government
Pension Based on His/Her Own Earnings
YES

NO (Go to III.K.)

a. Date Last Employed:
b. Covered by Social Security on Date in 1.a. Above
YES (GO TO III.K.)

NO

2. Agency or Organization From Which Government Pension or Annuity Received.
a. Name of Agency:
b. Address:
3. Amount of Pension:
4. Frequency of Payment:
5. Date First Eligible to Pension:
6. Date First Entitled to Pension:
(IF DATE IN 5 OR 6 ABOVE IS BEFORE 7/1/83, ANSWER 7 BELOW)
7. One-half Support Established
YES

NO

8. Spouse/Divorced Spouse/Surviving Spouse/Surviving Divorced Spouse Meets an Exception to
Government Pension Offset
YES

NO

9. Offset Amount
a. Amount of Offset in Sample Month/Review Period: $
b. Monthly Benefit Paid (Benefit After Offset):

$

Remarks:

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FIELD/TELEPHONE REVIEW
III.

SPOUSE/SURVIVING SPOUSE
J. Government Pension Offset

Consolidated Review
J. GPO

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain and Obtain Verification, if Necessary)

Development/Findings/Remarks:

GO TO PART V., PAGE 28, IF NO CHILDREN ARE IN THE SCOPE OF REVIEW
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III.

SPOUSE/SURVIVING SPOUSE
K. Child-In-Care

NOT APPLICABLE

COMPLETE THIS SECTION ONLY TO THE EXTENT NECESSARY TO ESTABLISH THAT ONE CHILD OF
THE NH IS IN THE BENEFICIARY'S CARE.
1. Child-in Care Is Under Age 16 or Mentally Incompetent, and Living with the Beneficiary.
YES (Complete Below)

NO

a. BIC(s) of Child-in-Care:
b. Claims Folder Indicates That Parental Control and Responsibility Are Exercised.
YES

NO (Explain Below)

2. Child-in-Care Is Disabled, Mentally Competent, and Age 16 or Over.
YES (Complete Below)

NO

a. BIC(s) of Child-in-Care:
b. Explain Nature of Personal Services Rendered:

3. If a child is not living with the beneficiary, describe the living situation of the child and whether the
claim folder indicates that the beneficiary exercises parental control and responsibility.

Remarks:

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FIELD/TELEPHONE REVIEW
III.

SPOUSE/SURVIVING SPOUSE
K. Child-In-Care

Consolidated Review
NOT APPLICABLE

K. Child-In-Care

1. Child-In Care is Under Age 16 or Mentally Incompetent, and Living
with the Beneficiary.
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Enter Name of Child:
Observed

Not Observed (Obtain
Verification of Existence)

Describe the nature of parental control and responsibility exercised
by the beneficiary:

2. Child-In-Care is Disabled, Mentally Competent, Age 16 or over and
Living with the Beneficiary
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Enter Name of Child:
Observed

Not Observed (Obtain
Verification of Existence)

Obtain SSA-795's from the beneficiary and the child describing the
nature and frequency of personal service rendered by the beneficiary
and to what extent the beneficiaries presence is required because of
the child's disability.
3. There is a Child, as Described in 1. or 2. Above, Who is Not Living
with the Beneficiary
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Enter Name of Child:
Observed

Not Observed (Obtain
Verification of Existence)

Complete SSA-781 and Obtain Other Necessary Verification
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IV.

CHILD

NOT APPLICABLE

A. Identity
1. BIC

2. Name

3. SSN (BOAN)

B. Application
1. BIC

2. Type of
Benefit

3. Date Claim
Filed

4. Date of
Entitlement

5. Was any child beneficiary previously entitled to benefits (including SSI) on this or any other SSN?
YES (BIC(s)

Explain Below)

6. Unresolved Claims Issues: BIC(s)

NO

NONE APPLY

Unprocessed Application

Deemed Filing

Delayed Claim

Protective Filing

Open Application

Partial Adjudication

Potential Entitlement

Explain

7. Month of Entitlement Determined by Desk Review:
BIC

MOE

BIC

MOE

BIC

MOE

BIC

MOE

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FIELD/TELEPHONE REVIEW
IV.

CHILD

Consolidated Review

A. Identity
1. BIC

NOT APPLICABLE
2. Existence Verified By

B. Application

A. Identity

3. SSN Verified By

B. Application

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

Development/Findings/Remarks:

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IV.

CHILD

C. Multiple Entitlement Involved
YES (BIC

Claim Number

)

(BIC

Claim Number

)

(BIC

Claim Number

)

(BIC

Claim Number

)

NO

D. Recovery of Overpayment in Sample Month/Review Period
YES (Complete Below)
1. BIC

NO

2. Total Amount of Overpayment
$
$
$
$

E. Prior Underpayment on Sampled SSN Needed to be Addressed
YES

NO

F. Payment Amount(s)
1. BIC

Amount of
PMA Check

Period

Amount of
CMA Check

$

$

$

$

$

$

$

$

Period

Remarks:

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FIELD/TELEPHONE REVIEW
IV.

CHILD

Consolidated Review

C. Multiple Entitlement Involved

C. Multiple Entitlement

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

D. Recovery of Overpayment in SM/Review Period

D. Recovery of Overpayment
in SM/Review Period

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

E. Prior Underpayment on Sampled SSN
Beneficiary Agrees With DR Summary

E. Prior U/P on Sampled
SSN

Beneficiary Disagrees With DR Summary:
(Explain)

F. Payment Amount(s)

F. Payment Amount(s)

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

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IV.

CHILD

G. Date Of Birth
1. BIC:
a. Date of Birth and Proof Code on N3R Printout:
b. Place of Birth:

c. MN:

FN:

d. Evidence/Documentation in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
f. Date of Birth Established by Desk Review:
2. BIC:
a. Date of Birth and Proof Code on N3R Printout:
b. Place of Birth:

c. MN:

FN:

d. Evidence/Documentation in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
f. Date of Birth Established by Desk Review:
3. BIC:
a. Date of Birth and Proof Code on N3R Printout:
b. Place of Birth:

c. MN:

FN:

d. Evidence/Documentation in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
f. Date of Birth Established by Desk Review:
4. BIC:
a. Date of Birth and Proof Code on N3R Printout:
b. Place of Birth:

c. MN:

FN:

d. Evidence/Documentation in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
f. Date of Birth Established by Desk Review:

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FIELD/TELEPHONE REVIEW
IV.

CHILD

Consolidated Review

G. Date of Birth

G. Date of Birth

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

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DESK REVIEW
IV.

CHILD

H. Relationship/Dependency/Support
1. BIC:

2. BIC:

a. Type of Child:

a. Type of Child:

b. Deemed Support:

YES

NO

c. Support Period:

b. Deemed Support:

YES

NO

YES

NO

YES

NO

c. Support Period:

d. Living With:

YES

NO

d. Living With:

e. Contributions:

e. Contributions:

f. 1/2 Support Established:

f. 1/2 Support Established:
YES

NO

g. Evidence of Relationship:

g. Evidence of Relationship:

3. BIC:

4. BIC:

a. Type of Child:

a. Type of Child:

b. Deemed Support:

YES

NO

c. Support Period:

b. Deemed Support:

YES

NO

YES

NO

YES

NO

c. Support Period:

d. Living With:

YES

NO

d. Living With:

e. Contributions:

e. Contributions:

f. 1/2 Support Established:

f. 1/2 Support Established:
YES

g. Evidence of Relationship:

NO

g. Evidence of Relationship:

5. Entitled Child Adopted or Equitably Adopted by Someone Other Than Number Holder.
YES (Complete Below)
a. BIC:

NO
b. BIC:

1. Name of Child:

1. Name of Child:

2. Date of Adoption:

2. Date of Adoption:

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FIELD/TELEPHONE REVIEW
IV.

CHILD

Consolidated Review

H. Relationship/Dependency/Support
Beneficiary Agrees With DR Summary

H. Relationship/
Dependency/
Support

Beneficiary Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

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IV.

CHILD

I. Marriage
1. Has any child beneficiary ever been married?
YES (Complete Below)

NO

a. BIC:
b. Current/Last Marriage to:
c. Age/Date of Birth:

d. SSN:

e. Date of Marriage:

f. Type:

g. Place of Marriage:
h. How Terminated:

i. Date Terminated:

j. Place Terminated:
k. Evidence/Documentation in Claims Folder/MCS Screens:
l. Evidence Needing Verification:
2. Child's spouse is a Title II Beneficiary
YES (Spouse's Claim Number:

NO

)
J. School Attendance
1. BIC(s):

2. Name of School:

3. School Is "Educational Institution"

YES

NO

YES

NO

(If NO, Explain)
4. Student Beneficiary Paid by Employer
(If YES, Explain)
5. Evidence/Documentation in Claims Folder)MCS Screens:
6. Evidence Needing Verification:
Remarks:

Form SSA-2931-BK (07-2000)
Destroy All Prior Editions

EF (11-2000)
Page 26 of 30

FIELD/TELEPHONE REVIEW
IV.

CHILD

Consolidated Review

I. Marriage

I. Marriage

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

J. School Attendance

J. School Attendance

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

Development/Findings/Remarks:

Form SSA-2931-BK (07-2000)
Destroy All Prior Editions

EF (11-2000)
Page 27 of 30

DESK REVIEW
V. ADDITIONAL ISSUES
A. SMI Determination

NOT APPLICABLE

The SMI Determination, including the premium deduction and penalty amounts (if any), is correct.
YES

NO (BIC

Explain)

B. Misinformation/Contact With SSA Prior to Date Claim Filed
Would it have been to the number holder's advantage to file for benefits at an earlier date?
YES (BIC

Explain)

NO

C. Criminal Activities
BIC(s)

Not Involved in Any Criminal Activities Listed Below

Homicide

Subversive Activities

Deportation

Imprisonment for a Felony

Offenses Against the National
Security (Hiss Act)
Beneficiary Entitled on Basis of His Own Disability and that Disability Appears to Have Occurred or
Was Aggravated by the Commission of a Felony After October 19, 1980, and for which the Person Was
Convicted
Evidence Needing Verification: BIC

D. Representative payee
Does the claims folder indicate an unresolved representative payee issue (need for payee change, etc.) for
the sampled number holder?
YES

(BIC

Explain)

(BIC

Explain)

Form SSA-2931-BK (07-2000)
Destroy All Prior Editions

NO

EF (11-2000)
Page 28 of 30

FIELD/TELEPHONE REVIEW
V. ADDITIONAL ISSUES

Consolidated Review

A. SMI Determination

A. SMI Determination

Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)

B. Misinformation/Contact With SSA Prior to Date Claim Filed

B. Misinformation/Contact With
SSA Prior to DCF

If V.B. of the desk review summary is answered YES, did the
number holder inquire about filing at an earlier time?
(Explain)

C. Criminal Activities

C. Criminal Activities

If any of the criminal activities listed in V.C. of the desk review
summary are involved, discuss and resolve below.

D. Representative Payee

D. Representative Payee

There is an indication that an unresolved representative payee
issue exists (need for payee change, etc.) for the sampled number
holder.
YES (BIC

Explain)

(BIC

Explain)

Form SSA-2931-BK (07-2000)
Destroy All Prior Editions

NO

EF (11-2000)
Page 29 of 30

CASE SUMMARY
V. ADDITIONAL ISSUES
E. Consolidated Review Summary
Desk and field review findings are in agreement.
Desk and field review findings are not in agreement. Indicate the section(s) where the disagreement
exists.
Deceased/Nonsampled Number Holder:
II.A.

II.B.

II.C.

II.D.

II.E.

II.F.

III.A.

III.B.

III.C.

III.D.

III.E.

III.F.

III.G.

III.H.

III.I.

III.J.

III.K.

IV.A.

IV.B.

IV.C.

IV.D.

IV.E.

IV.G.

IV.H.

IV.I.

IV.J.

V.B.

V.C.

V.D.

Spouse/Surviving Spouse:

Child
IV.F.

Additional Issues:
V.A.

Additional Development/Findings/Remarks:

Signature of Reviewer(s)
Date:
Desk Reviewer
Date:
Field Reviewer
Date:
Consolidated Reviewer
Form SSA-2931-BK (07-2000)
Destroy All Prior Editions

Page 30 of 30

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