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

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0189

RSI/DI QUALITY REVIEW CASE ANALYSIS – AUXILIARY/SURVIVING SPOUSE AND CHILDREN

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 the 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 30 minutes to read the instructions, gather the necessary facts, and answer the questions.

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. Review Amount Determined by QR: $

     

F. Explanation of SCL Changes, if Any:

     

G. Type of Interview:

Face-to-Face

Telephone

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:

(   )

     

Beneficiary Entitled in Closed Year and Subject to Annual Earnings Test (Complete SSA-4281/SSA-4659)

Additional Beneficiaries In Scope of Review (Complete Separate SSA-2931)

II. DECEASED/NONSAMPLED NUMBER HOLDER

A. Number Holder Information

Deceased Number Holder

Nonsampled Number Holder

B. Other Names and SSNs Shown in File/Numident

1. Other Names:

     

     

2. Other SSNs:

     

     

C. Date of Birth

NOT APPLICABLE

1. Date of Birth and Proof Code on MBR Printout:

     

     

2. Place of Birth:

     

3. MN:

     

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:

     

E. Are there any eligible children of the NH who have not filed for benefits?

YES (Explain)

NO

     

II. DECEASED/NONSAMPLED NUMBER HOLDER						Consolidated Review
	A. Number Holder Information					A. Number Holder Information
		Deceased NH		Nonsampled NH		     
	B. Other Names and SSNs Used					B. Other Names/SSNs
		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				NOT APPLICABLE	D. Date of Death
		Beneficiary Agrees With DR Summary				     
		Beneficiary Disagrees With DR Summary:
		 (Explain)      
		 Evidence Obtained in Field Review:      
	E. Eligible Children					E. Eligible Children
		Beneficiary Agrees With DR Summary				     
		Beneficiary Disagrees With DR Summary:
		 (Explain)      

II. DECEASED/NONSAMPLED NUMBER HOLDER
F. 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:      

II. DECEASED/NONSAMPLED NUMBER HOLDER

F. 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:

     

II. DECEASED/NONSAMPLED NUMBER HOLDER

G. Computation Information

1. Work Issues

Explanation

Wages

     

Self-Employment

     

Lag Wages/SEI

     

Gaps

     

Annual Reports

     

Other

     

2. Military Service

NONE

a. Branch of Service:

     

b. Serial Number:

     

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

From

     

To

     

ALG PRV PRE

From

     

To

     

ALG PRV PRE

d. If MS prior to 1957, NH Receives/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 5 or more years of railroad work alleged?

YES

NO

4. Prior Period(s) of Disability

NONE

a. PPD Shown on MBR:

Date of Onset:

     

Term Date:

     

b. Documentation in File:

     

c. PPD Established by Desk Review:

Date of Onset:

     

Term Date:

     

II. DECEASED/NONSAMPLED NUMBER HOLDER									Consolidated Review
		G. Computation Information							G. Computation Information
	1. Work Issues								1. Work Issues
	Beneficiary Agrees With DR Summary								     
	     
	Beneficiary Disagrees With DR Summary:
			Year		Amount on E/R			Amount Alleged
			    		     			     
			    		     			     
	 Evidence Obtained in Field Review:      
	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)      

III. SPOUSE/SURVIVING SPOUSE

A. Identity

1. Name:

     

2. SSN (BOAN):

     

B. Other Names and SSNs Shown in Claims Folder/Numident

1. Other Names:

     

     

2. Other SSNs:

     

     

C. Date of Birth/Citizenship

1. Date of Birth and Proof Code on MBR Printout:

     

     

2. Place of Birth:

     

3. MN:

     

FN:

     

4. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien

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

 6. Evidence Needing Verification:      

7. Date of Birth Established by Desk Review:

     

8. Citizenship/Alien Status Established by Desk Review:

     

Remarks:

     

III. SPOUSE/SURVIVING SPOUSE								Consolidated Review
A. Identity								A. Identity
	1. Existence Verified by:							     
		Observation			Photo ID	     
		Other:		     
		2. SSN Verified by:			SSN Card		Medicare Card
			Other:	     
B. Other Names and SSNs Used								B. Other Names/SSN’s
		Beneficiary Agrees With DR Summary						     
		Beneficiary Disagrees With DR Summary:
		 (Explain)      
C. Date of Birth and Citizenship/Alien Status								C. DOB and Citizenship/Alien
		Beneficiary Agrees With DR Summary						     
		Beneficiary Disagrees With DR Summary:
		 (Explain)      
		 Evidence Obtained in Field Review:      

III. SPOUSE/SURVIVING SPOUSE
D. Application
1. Date Claim Filed:	     
2. DOE and MOEL Option Code:	     			     
3. DOE Determined by Desk Review:	     

E. Multiple Entitlement Involved: YES (Complete Below) NO

1. Claim Number on Non-sampled SSN:	     
2. Scope of Review on Non-sampled SSN:
Full Review Limited Review Not in Scope of Review

F. Potential Entitlement on Own SSN: NOT APPLICABLE (Go to III.G)

Wages	     
Self-Employment	     
Lag Wages/SEI	     
Gaps	     
Other	     
Military Service	     
Foreign Work	     
Insured Status Met	     

G. Other Claims Activity

1. Did the beneficiary ever file for any other benefits (including SSI)?
YES (Explain)				NO
		     
2. Unadjudicated Claims Issues:							NONE APPLY
	Unprocessed Application				Deemed Filing
	Protective Filing				Open Application
	Partial Adjudication				Other Potential Entitlement (Leads)
	Delayed Claim				Misinformation
(Explain)      

III. SPOUSE/SURVIVING SPOUSE							Consolidated Review
D. Application							D. Application
	Beneficiary Agrees With DR Summary						     
	Beneficiary Disagrees With DR Summary
	(Explain)		     
E. Multiple Entitlement							E. Multiple Entitlement
	Beneficiary Agrees With DR Summary						     
	Beneficiary Disagrees With DR Summary
	 (Explain)      
F. Potential Entitlement on Own SSN NOT APPLICABLE							F. Potential Entitlement
	Beneficiary Agrees With DR Summary						     
	     
	Beneficiary Disagrees With DR Summary:
	Year			Amount on E/R		Amount Alleged
	    			     		     
	    			     		     
	 Evidence Obtained in Field Review:      
G. Other Claims Activity							G. Other Claims Activity
	Beneficiary Agrees With DR Summary						     
	Beneficiary Disagrees With DR Summary
	 (Explain)      

III. SPOUSE/SURVIVING SPOUSE
H. 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:
	    

III. SPOUSE/SURVIVING SPOUSE

H. 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:      III. SPOUSE/SURVIVING SPOUSE

III. SPOUSE/SURVIVING SPOUSE

I. Government Pension Offset

COMPLETE IF SPOUSE/SURV SPOUSE WAS ENTITLED/FILED DECEMBER 1, 1977 OR LATER.

1. Spouse/Surviving Spouse is Entitled to a Government Pension Based on His/Her Own Earnings.

YES

NO (Go to III.J.)

2. Agency or Organization From Which Government Pension or Annuity Received

a. Name of Agency:

     

b. Address:

     

3. Date First Entitled to Pension:

     

4. Date First Eligible:

     

5. GPO Exception Met (Check Any that Apply and Go to I.7.)

Date First Eligible Prior to 12/01/82 and Entitlement Requirements in Effect in 01/77 Met

For Benefits 12/82 or Later, First Eligible Prior to 07/83 and One-Half Support Met

For Benefits 12/84 or Later, Would Have Been Eligible in 11/82 or 6/83 but Payment Delayed

Federal Employee Filed an Election for Coverage under Social Security or Mandatory Coverage Applies or Worked under Covered Federal Employment for at Least 60 Months before DOE

For Benefits 1/95 or Later, Receives a Military Pension Based on Non-Covered Reserve Service

State/Local Govt. Employee Filed for Social Security Prior to 4/04 or Retired from Govt. Service Prior to 7/04 AND Last day of Work Covered under Social Security

State/Local Govt. Employee Filed for Social Security After 3/04 or Retired from Govt. Service After 6/04 AND Last 60 Months of Work (less if last work prior to 3/09) Covered under Social Security

6. If None of the Exceptions in I.5 are met:

a. Amount of Pension: $

     

b. Frequency of Payment:

     

c. Amount of Offset in Sample Month: $

     

d. Monthly Benefit After Offset: $

     

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

    

8. Evidence Needing Verification:

     

III. SPOUSE/SURVIVING SPOUSE						Consolidated Review
	I. Government Pension Offset					I. GPO
	Beneficiary Agrees With DR Summary					     
	Beneficiary Disagrees With DR Summary:
	(Explain)
	     
Evidence Obtained in Field Review:
     

III. SPOUSE/SURVIVING SPOUSE

J. Child-in-Care

NOT APPLICABLE (Go to III.K)

COMPLETE TO ESTABLISH THAT A CHILD OF THE NH IS IN THE BENEFICIARY’S CARE

1. Child-in-Care Under Age 16 or Mentally Disabled, Beneficiary Exercises Parental Control

YES (Complete Below)

NO (Go to J.2)

a. BIC(s) of Child-in-Care:

     

b. Child-in-Care is Living with the Beneficiary

Child-In-Care is Not Living with Beneficiary (Explain)

     

2. Child-in-Care Age 16 or Older and Physically Disabled, Beneficiary Performs Personal Services

YES (Complete Below)

NO (Go to J.3)

a. BIC(s) of Child-in-Care:

     

b. Child-in-Care is Living with the Beneficiary

Child-In-Care is Not Living with Beneficiary

c. Nature and Frequency of Personal Services:

     

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

     

4. Evidence Needing Verification:

     

III. SPOUSE/SURVIVING SPOUSE

Consolidated Review

J. Child-In-Care

NOT APPLICABLE

J. Child-In-Care

1. Child-In-Care Under 16 or Mentally Disabled, Living with Beneficiary

     

Beneficiary Agrees With DR Summary

Beneficiary Disagrees With DR Summary (Explain)

     

a. If CIC, describe the nature and extent of parental control/responsibility:

     

b. If CIC, Verification of Child’s Existence and Residence Child Observed in Home (in person or by phone)

Child Observed in Home ( in person or by phone)

Child Not Observed in Home

Existence Verified by QQQQQQQQQQQQQQQ

Residence Verified by QQQQQQQQQQQQQQQ

     

     

2. Child-In-Care 16 or Older & Physically Disabled, Living w/ Beneficiary

Beneficiary Agrees With DR Summary

Beneficiary Disagrees With DR Summary (Explain)

     

a. If CIC, describe the nature/frequency of personal services and extent beneficiary’s presence required because of the child’s disability:

     

b. If CIC, Verification of Child’s Existence and Residence

Child Observed in Home (in person or by phone)

Child Not Observed in Home

Existence Verified by QQQQQQQQQQQQQQQ

Residence Verified by QQQQQQQQQQQQQQQ

     

     

c. If CIC, child’s description of the nature/frequency of personal services:

     

3. Child, as Described in 1. or 2. Above, Not Living with the Beneficiary

Beneficiary Agrees With DR Summary

Beneficiary Disagrees With DR Summary (Explain)

     

a. If CIC, SSA-781 Obtained from Beneficiary: Yes No

b. Verification of Child’s Existence and Child-in-Care (QRM 3612):

Custodian School Child Other      

III. SPOUSE/SURVIVING SPOUSE
K. Current DWB or Deemed DWB Entitlement						NOT APPLICABLE (Go to IV.)
	1. Period(s) of Disability
	a. Established Onset Date:		     		b. Date of Entitlement:		     
	c. Disabled Before End of Prescribed Period: YES NO (Explain)
		     
	d. Prior or Current Entitlement to SSI/SSP Benefits: YES (If Yes, go to e.) NO
	e. Waiting Period(s) Reduced by SSI/SSP Credit: YES NO (Explain)
		     
	2. Disability-Related Work Information
	a. Earnings After Current Established Onset Date: YES (Complete Below) NO
		     
	b. Disability-Related Work Issues			Explanation
	Trial Work Period			     
	Substantial Gainful Activity			     
	Unsuccessful Work Attempt			     
	Cessation			     
	Extended Period of Eligibility			     
	Termination			     
	Expedited Reinstatement			     
	Other			     
	 c. Evidence/Documentation in File:      
	 d. Evidence Needing Verification:      

III. SPOUSE/SURVIVING SPOUSE						Consolidated Review
	K. Current DWB or Deemed DWB Entitlement					K. Current DWB Entitlement
		1. Period(s) of Disability				1. Period(s) of Disability
		Beneficiary Agrees With DR Summary				     
		Beneficiary Disagrees With DR Summary
			(Explain)
			     
		2. Disability-Related Work Information				2. Disability-Related Work Info
		Beneficiary Agrees With DR Summary				     
		Beneficiary Disagrees With DR Summary
			(Explain)
			     
			Evidence Obtained in Field Review:
			     

IV. CHILD

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. Date of Entitlement Determined by Desk Review

BIC

   

DOE

     

BIC

   

DOE

     

BIC

   

DOE

     

BIC

   

DOE

    

C. Multiple Entitlement Involved

YES (BIC

   

Claim Number

     

)

NO

(BIC

   

Claim Number

     

)

(BIC

   

Claim Number

     

)

(BIC

   

Claim Number

     

)

D. Other Claims Activity

1. Did any child beneficiary ever file for any other benefits (including SSI)?

YES (BIC(s)

    

     

(Explain)

NO

     

2. Unadjudicated Claims Issues: BIC(s):

    

    

NONE APPLY

Unprocessed Application

Deemed Filing

Delayed Claim

Protective Filing

Open Application

Misinformation

Partial Adjudication

Potential Entitlement on Another Parent’s SSN

Explain:

     

IV. CHILD								Consolidated Review
	A. Identity							A. Identity
		1. BIC		2. Existence Verified By		3. SSN Verified By		     
			   		     		     
			   		     		     
			   		     		     
			   		     		     
	B. Application							B. Application
		Beneficiary Agrees With DR Summary						     
		Beneficiary Disagrees With DR Summary:
		(Explain)
		     
	C. Multiple Entitlement							C Multiple Entitlement
		Beneficiary Agrees With DR Summary						     
		Beneficiary Disagrees With DR Summary:
		(Explain)
		     
	D. Other Claims Activity							D. Other Claims Activity
		Beneficiary Agrees With DR Summary						     
		Beneficiary Disagrees With DR Summary:
		(Explain)
		     

IV. CHILD

E. Date of Birth

1. BIC:

     

a. Date of Birth and Proof Code on MBR Printout:

     

   

b. Place of Birth:

     

c. MN:

     

FN:

     

c. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien

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

     

e. Evidence Needing Verification:

     

f. Date of Birth Established by Desk Review:

     

g. Citizenship/Alien Status Established by Desk Review:

     

2. BIC:

     

a. Date of Birth and Proof Code on MBR Printout:

     

   

b. Place of Birth:

     

c. MN:

     

FN:

     

c. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien

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

     

e. Evidence Needing Verification:

     

f. Date of Birth Established by Desk Review:

     

g. Citizenship/Alien Status Established by Desk Review:

     

3. BIC:

     

a. Date of Birth and Proof Code on MBR Printout:

     

   

b. Place of Birth:

     

c. MN:

     

FN:

     

c. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien

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

     

e. Evidence Needing Verification:

     

f. Date of Birth Established by Desk Review:

     

g. Citizenship/Alien Status Established by Desk Review:

     

4. BIC:

     

a. Date of Birth and Proof Code on MBR Printout:

     

   

b. Place of Birth:

     

c. MN:

     

FN:

     

c. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien

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

     

e. Evidence Needing Verification:

     

f. Date of Birth Established by Desk Review:

     

g. Citizenship/Alien Status Established by Desk Review:

     

IV. CHILD					Consolidated Review
	E. Date of Birth and Citizenship/Alien Status				E. DOB and Citizenship/Alien
		Beneficiary Agrees With DR Summary			     
		Beneficiary Disagrees With DR Summary:
		(Explain)
		     
		Evidence Obtained in Field Review:
		     

IV. CHILD
	F. Relationship and Dependency
		1. BIC:			    	a. Type of Child Relationship:			     
		b. Child Adopted or Equitably Adopted by Someone other than Number Holder: YES NO
		c. Deemed Dependency: YES (Go to d.)						NO Support Period:		     
Dependency Requirement(s) that Applies: Living With Contributions ½ Support
			d. Evidence/Documentation of Relationship/Dependency in Claims Folder/MCS Screens:
				     
			e. Evidence Needing Verification:				     
		2. BIC:			    	a. Type of Child Relationship:			     
		b. Child Adopted or Equitably Adopted by Someone other than Number Holder: YES NO
		c. Deemed Dependency: YES (Go to d.)						NO Support Period:		     
Dependency Requirement(s) that Applies: Living With Contributions ½ Support
			d. Evidence/Documentation of Relationship/Dependency in Claims Folder/MCS Screens:
				     
			e. Evidence Needing Verification:				     
		3. BIC:			    	a. Type of Child Relationship:			     
		b. Child Adopted or Equitably Adopted by Someone other than Number Holder: YES NO
		c. Deemed Dependency: YES (Go to d.)						NO Support Period:		     
Dependency Requirement(s) that Applies: Living With Contributions ½ Support
			d. Evidence/Documentation of Relationship/Dependency in Claims Folder/MCS Screens:
				     
			e. Evidence Needing Verification:				     
		4. BIC:			    	a. Type of Child Relationship:			     
		b. Child Adopted or Equitably Adopted by Someone other than Number Holder: YES NO
		c. Deemed Dependency: YES (Go to d.)						NO Support Period:		     
Dependency Requirement(s) that Applies: Living With Contributions ½ Support
			d. Evidence/Documentation of Relationship/Dependency in Claims Folder/MCS Screens:
				     
			e. Evidence Needing Verification:				     

IV. CHILD					Consolidated Review
	F. Relationship and Dependency				F. Relationship and Dependency
		Beneficiary Agrees With DR Summary			     
		Beneficiary Disagrees With DR Summary:
		(Explain)
		     
		Evidence Obtained in Field Review:
		     

IV. CHILD

G. 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 NO (If Yes, Claim Number):

     

H. School Attendance NOT APPLICABLE

1. BIC(s):

     

 2. Name and Address of School:      

3. Full-Time Attendance or Deemed Full-Time Attendance in Sample Month:

YES NO

(If NO, Explain)

     

4. School is “Educational Institution”:

YES

NO

(If NO, Explain)

     

5. Student Beneficiary Paid by Employer:

YES

NO

(If YES, Explain)

     

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

     

7. Evidence Needing Verification:

     

IV. CHILD						Consolidated Review
		G. Marriage				G. Marriage
			Beneficiary Agrees With DR Summary			     
			Beneficiary Disagrees With DR Summary:
			(Explain))
			     
			Evidence Obtained in Field Review:
			     
	H. School Attendance					H. School Attendance
			Beneficiary Agrees With DR Summary			     
			Beneficiary Disagrees With DR Summary:
			(Explain)
			     
			Evidence Obtained in Field Review:
			     

IV. CHILD
	I. Current DAC Entitlement					NOT APPLICABLE (Go to V.)
		1. Period(s) of Disability:
		a. BIC(s):	     		b. Established Onset Date:		     
		c. Disabled before Age 22 or Re-Entitled & Disabled Within Applicable Timeframe: YES NO
		(Explain)	     
		2. Disability-Related Work Information:
		a. Earnings After Current Established Onset Date: YES (Explain) NO
		     
		b. Disability-Related Work Issues			Explanation
		Trial Work Period			     
		Substantial Gainful Activity			     
		Unsuccessful Work Attempt			     
		Cessation			     
		Extended Period of Eligibility			     
		Termination			     
		Expedited Reinstatement			     
		Other			     
		 c. Evidence/Documentation in File:      
		 d. Evidence Needing Verification:      
		3. Potential Entitlement on Own SSN: CURRENTLY ENTITLED (Go to V.)
		Wages		     
		Self-Employment		     
		Lag Wages/SEI		     
		Gaps		     
		Other		     
		Insured Status Met		     

IV. CHILD							Consolidated Review
	I. Current DAC Entitlement						I. Current DAC Entitlement
	1. Period(s) of Disability						1. Period(s) of Disability
Beneficiary Agrees With DR Summary							     
Beneficiary Disagrees With DR Summary
	 (Explain)      
	2. Disability-Related Work Information						2. Disability-Related Work Info
Beneficiary Agrees With DR Summary							     
Beneficiary Disagrees With DR Summary
	 (Explain)      
	 Evidence Obtained in Field Review:      
	3. Potential Entitlement on Own SSN						3. Potential Entitlement
	Beneficiary Agrees With DR Summary						     
	     
	Beneficiary Disagrees With DR Summary:
	Year		Amount on E/R			Amount Alleged
	    		     			     
	    		     			     
	Evidence Obtained in Field Review:
	     

V. PAYMENT FOR THE SAMPLE MONTH

A. Underpayment on Sampled SSN Needed to Be Addressed:

YES (Explain)

NO

     

B. Recovery of Overpayment in Sample Month:

YES (Explain)

NO

     

C. SMI Determination

NOT APPLICABLE

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

YES

NO (Explain)

     

D. Payment Amount(s)

1. BIC

2. Amount of CMA/SM Check

3. Sample Month

4. Payment Cycle Indicator (CYI)

   

$

     

     

     

   

$

     

     

     

   

$

     

     

     

   

$

     

     

     

5. Payment Combined with Other Benefit: YES NO

6. Check Amount Affected by Other Withholding (e.g., Medicare C/D Premiums, Voluntary Tax Withholding, Garnishment, Treasury Offset Program, etc.):

YES (Explain)

NO

     

V. PAYMENT FOR THE SAMPLE MONTH		Consolidated Review
A. Underpayment on Sampled SSN		A. Underpayment      
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
 (Explain)      
B. Recovery of Overpayment in Sample Month		B. Overpayment
Beneficiary Agrees With DR Summary		     
Beneficiary Disagrees With DR Summary:
 (Explain)      
C. SMI Determination		C. SMI Determination
Beneficiary Agrees With DR Summary	     
Beneficiary Disagrees With DR Summary:
 (Explain)      
D. Payment Amount		D. Payment Amount
Beneficiary Agrees With DR Summary	     
Beneficiary Disagrees With DR Summary:
 (Explain)      

VI. ADDITIONAL ISSUES

A. Fugitive Felon

BICs over Age 12:

     

Are there any unsatisfied felony warrants for arrest or for violations of probation/parole?

YES (Complete below) NO

Evidence/Documentation in Claims Folder/MCS Screens:

     

Evidence Needing Verification:

     

B. Criminal Activities

BICs

     

Not Involved in Criminal Activities Listed Below

BICs

     

Are Involved in Criminal Activities Listed Below

Homicide of NH

Subversive Activities

Removal (formerly Deportation)

Confined for a Criminal Offense

Offenses Against the National Security (Hiss Act)

Disability Determination Based on a Condition That Occurred During the Commission of a Felony After October 19, 1980

Disability Determination Based on a Condition That Occurred During Confinement for a Felony Conviction

Evidence/Documentation in Claims Folder/MCS Screens:

     

 Evidence Needing Verification:      

C. Representative Payee

Does the claims folder indicate an unresolved representative payee issue (need for payee change, etc.) for a sampled beneficiary?

YES (BIC

   

Explain)

NO

(BIC

   

Explain)

     

VI. ADDITIONAL ISSUES

Consolidated Review

A. Fugitive Felon

A. Fugitive Felon

All beneficiaries state/desk review summary shows that there are no unsatisfied felony warrants for arrest or for violations of probation/parole.

     

YES

NO (Explain)

     

Evidence Obtained in Field Review:

     

B. Criminal Activities

B. Criminal Activities

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

     

     

C. Representative Payee

C. Representative Payee.

There is an indication that an unresolved representative payee issue exists (need for payee change, etc.) for a sampled beneficiary.

     

YES (BIC

   

Explain)

NO

(BIC

   

Explain)

     

VI. ADDITIONAL ISSUES

D. 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.

Number Holder:

II.A.

II.B.

II.C.

II.D.

II.E.

II.F.

II.G.

Spouse:

III.A.

III.B.

III.C.

III.D.

III.E.

III.F.

III.G.

III.H.

III.I.

III.J.

III.K.

Child:

IV.A

IV.B.

IV.C.

IV.D.

IV.E.

IV.F.

IV.G.

IV.H.

III.I.

Payment for SM:

V.A.

V.B.

V.C.

V.D.

Additional Issues:

VI.A.

VI.B.

VI.C.

Additional Development/Findings/Remarks:

     

Signature of Reviewer(s):

     

Date:

     

Desk Reviewer

     

Date:

     

Field Reviewer

     

Date:

     

Consolidated Reviewer

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