Form Approved SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0189 |
STEWARDSHIP AET WORKBOOK
NUMBER HOLDER’S NAME |
NUMBER HOLDER’S SSN
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BENEFICIARY’S NAME AND BIC
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X-REFERENCE CLAIM NUMBER
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SAMPLE MONTH AND YEAR
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CLOSED YEAR
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NOTE TO REVIEWER: In opening the interview, 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. Tell them that this review consists of asking questions about their entitlement to Social Security benefits and that we may 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 from time to time the entitlement of beneficiaries.
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. The beneficiary is not required 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.
DESK REVIEW |
PART I -- CLOSED YEAR EARNINGS, NONSERVICE MONTHS, AND SWP
MBR Annual Report Information
Closed Year |
Earnings Amount |
Non-Service Months |
LMETY |
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Closed Year Posted Earnings--As shown on the SEQY/DEQY
Covered Earnings |
Noncovered Earnings |
Posted SWP |
Countable AET Earnings |
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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 (If No, describe the development needed to resolve the discrepancy.)
PART II -- ANNUAL REPORT PROCESSING
Did the beneficiary file an annual report for the closed year? Yes No
Were earnings for the closed year available on SSA records? Yes No
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? Yes No
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
FIELD REVIEW |
Date of Beneficiary Contact:
PART I -- CLOSED YEAR EARNINGS, NSM AND SWP
Wages -- List beneficiary's employment allegations for the two years before the closed year through the date of the interview. (Get W-2 forms for the closed year and subsequent year, unless the DEQY agrees with the beneficiary’s allegation. If earnings for the closed year are significantly lower than the years before and after, ask the reason for the decline.)
Employer Name |
Address |
Years(s) Employed |
Amount of Earnings |
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Closed Year |
Subsequent Year |
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Was the beneficiary a corporate officer/related to a corporate officer of a close or family corporation listed above? Yes No
(If Yes, complete an SSA-795 per QRM 8044. If applicable, get a copy of resignation from office and the corporate minutes accepting the resignation. If a questionable retirement issue is still not resolved, get copies of tax returns and any other available evidence.)
Self-Employment -- List beneficiary's self-employment allegations for the two years before the closed year through the date of the interview. (Certify or make copies of schedules C or F and SE for closed year and subsequent year, if filed.)
Name & Address of Business |
Type of Business |
Date Started |
Date Ended |
If Ended, Reason Ended |
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If business sold or transferred, give the name, address, and phone number of the present operator and relationship to the beneficiary:
Special Wage/SEI Payments -- List any special wage/SEI payments received by the beneficiary in or after the closed year for work performed in a prior period. (If material to payment for the closed year, get evidence showing the amount, date of payment, and type of payment.)
Employer/Payer |
Amount Received |
Type of Payment |
Date Received |
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FIELD REVIEW |
Non-service Months -- If LMETY not used before the closed year, enter the alleged closed year non-service months. Check the Wages block if beneficiary earned under the monthly AET limit in wages and/or the SE block if beneficiary was SE and did not render substantial services. (If alleged NSMs are material to payment for the closed year, get evidence of wage NSMs from the beneficiary or the employer. If SE, get the name/phone/address of people with knowledge & contact them for verification.)
Months |
Wages |
SE |
Months |
Wages |
SE |
Months |
Wages |
SE |
January |
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May |
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September |
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February |
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June |
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October |
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March |
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July |
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November |
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April |
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August |
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December |
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PART II -- ANNUAL REPORT INFORMATION
Did the beneficiary give AET information to SSA for the closed year? Yes No
If yes, when?
CONSOLIDATED REVIEW
Resolve any differences between desk review and field review findings:
CASE SUMMARY
Countable AET Earnings Established by QR |
If LMETY is Closed Year, NSM Established by QR |
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Do the payment adjustments, if any, made by SSA through the later of April 30 of the sample year or the last day of the sample month accurately reflect information for the closed year?
Yes No (Explain):
If there are any AET deficiencies which affect payment for the closed year, summarize here, code the error, and prepare the SSA-93 for corrective action.
REVIEWER’S SIGNATURE
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DATE
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Form SSA-4659-F4 (XX-XXXX) (Formerly SSA-4659-BK)
Destroy
all prior editions
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Form Approved |
Author | 500485 |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |