Form SSA-4659 Stewardship Annual Earnings Test Workbook

Form Approved
OMB No. 0960-0189

SOCIAL SECURITY ADMINISTRATION

STEWARDSHIP AET WORKBOOK
NOTE TO QR ANALYST: In opening the interview, ask if the beneficiaries received an
appointment letter. If the letter was not received, explain that this case is one of a small number
selected 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 may need to talk to others who may have information
about their entitlement. If necessary, point out that the Social Security Administration is
authorized by law to review from time to time the entitlement beneficiaries.
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 10 minutes to read the instructions, gather
the facts, and answer the questions. You may send comments on our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

IDENTIFYING INFORMATION
SAMPLE NUMBER HOLDER

NUMBER HOLDER SSN

BENEFICIARY'S NAME

BENEFICIARY'S SSN

SAMPLE MONTH AND YEAR

CLOSED YEAR

Form SSA-4659-F4 (9-1999) EF (08-2007) (Formerly SSA-4659-BK)
Destroy all prior editions

BIC

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PART I -- CLOSED YEAR EARNINGS, NSM AND SWP
DESK REVIEW

1. MBR Annual Report Information
Closed Year

Earnings Amount

Nonservice Months

LMETY Year

2. Closed Year Posted Earnings--As shown on the SEQY/DEQY
Covered Earnings

Noncovered Earnings

Posted SWP

Countable AET Earnings

Do the posted earnings and special wage payment (SWP) information from the DEQY for the
closed year agree with the Annual Report information from the MBR/Claims file?
Yes

No

(Explain in the space below the development needed to resolve the discrepancy)

General Guidelines for Field Review Evidence--see QRM 8400ff
Wages--Get W2 forms for the closed year and the subsequent year, unless DEQY agrees with
beneficiary's allegation.
If earnings for closed year are significantly lower than the years before and after, ask the reason for the
decline.
Corporate Officer--close or family corporation--In addition to the 795, if possible get a copy of
resignation from office, if applicable, and the corporate minutes accepting the resignation. If the
questionable retirement issue is still not resolved, get copies of tax returns and any other available
evidence.
Self-Employment--Certify or make copies of schedules C or F and SE for closed year and subsequent
year, if filed.
Special wage/SEI payments--If material to payment for the closed year, get evidence showing the
amount, date of payment, and type of payment.
Nonservice Months--Closed Year is LMETY Year--Alleged NSM Material to Payment for Closed
Year
Wages--Get evidence of NSM from the beneficiary or the employer.
Self-employment:--Get names/phone/address of people who can support the NSM allegations, and
contact for verification.

CONSOLIDATED REVIEW
Resolve any differences between the desk review & the field review

Form SSA-4659-F4 (9-1999) EF (08-2007)

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PART I (continued)--CLOSED YEAR EARNINGS, NSM AND SWP
FIELD REVIEW
Earnings in the AET Review Period
and
Date of Contact:
1. Wages--List beneficiary's employment allegations for two years before closed year through date
of interview.
Employer Name

Year(s)
Employed

Address

Amount of Earnings
Closed Year
Subsequent Year

Was beneficiary a corporate officer or related to a corporate officer in any of the above firms?
Yes
(Complete a 795 per QRM 8404)
No
2. Self-employment: List beneficiary's self-employment allegations for two years before closed year
through date of interview.
Name & Address of Business

Type of Business

Date Started

Date Ended

Reason Ended--i.e.
Transferred or Dissolved

If sold or transferred, give the name and address of the present operator and relationship to beneficiary:

3. Did beneficiary receive any special wage/SEI payments in or after the closed year for work in a
prior period where no work was actually done in the period received?
Employer/Payer

Amount Received

Type of Payment

Date Received

4. If LMETY not used before the closed year, enter the alleged closed year nonservice months.
Check wage blocks for months of earnings under the AET limit. Check NESE blocks for months
of no substantial services.
Wages

NESE

Months
January
February
March
April

Form SSA-4659-F4 (9-1999) EF (08-2007)

Wages

NESE

Months
May
June
July
August

Wages

NESE

Months
September
October
November
December
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PART II -- ANNUAL REPORT INFORMATION
DESK REVIEW
1. Was the beneficiary required to give AET information for the closed year?

Yes

No

2. Was AET information given or (beginning with 1996 closed year) were the
earnings available on SSA records?

Yes

No

3. If yes, was AET information given or were the earnings on SSA records by the
later of April 30 of the sample year or the last day of the sample month. (QRM 8075)?

Yes

No

4. If yes, did SSA process AET information by the later of April 30 of the sample
year or the last day of the sample month?

Yes

No

Yes

No

FIELD REVIEW
1. Did the beneficiary give AET information to SSA for the closed year?
2. If yes, when?

CONSOLIDATED REVIEW
Do the payment adjustments, if any, made by SSA through the later of April 30 or the last day
of the sample month accurately reflect information for the closed year?
Yes

No

(Resolve any differences between the desk review and field review)

PART III -- REVIEW FINDINGS FOR THE CLOSED YEAR
Countable AET Earnings Established by Review

If LEMETY is Closed Year, NSM from Review

Do the consolidated reviews show any AET discrepancies which affect payment for the closed
year?
Yes
No
If yes, summarize here, code the error, and prepare the SSA-93 for corrective action.

REVIEWER'S SIGNATURE

Form SSA-4659-F4 (9-1999) EF (08-2007)

DATE

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