Form SSA-2932 (revised) SSA-2932 (revised) RSI/DI Quality Review Case Analysis ? Parent

Form Approved
OMB No. 0960-0189

SOCIAL SECURITY ADMINISTRATION

RSI/DI QUALITY REVIEW CASE ANALYSIS — PARENT
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 from time to time the entitlement of beneficiaries.
The Paperwork Reduction Act of 1995
us toPRA
notify you that this information collection is in accordance
Seerequires
Revised
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. We estimate that it will take you about 20 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.

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. Beneficiary in Scope of Review
1. BIC
2. Name:
Address:

Phone:

(

)

3. Representative Payee
Name:
Address:

Phone:

(

)

Form SSA-2932-BK (11-1992) EF 11-2000

Page 1 of 10

DESK REVIEW
II. PARENT
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:
Remarks:

Form SSA-2932-BK (11-1992) EF 11-2000

Page 2 of 10

FIELD/TELEPHONE REVIEW
II. PARENT

Consolidated Review

A. Identity

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)

Form SSA-2932-BK (11-1992) EF 11-2000

Page 3 of 16

DESK REVIEW
II. PARENT
E. Recovery of Prior Overpayment in Sample Month/Review Period
YES (Complete Below)
Total Amount of Overpayment:

NO
$

F. Prior Underpayment on Sampled SSN Needed to Be Addressed
YES (Explain)

NO

G. Payment Amount(s)
1. Amount of PMA Check: $

, for Period(s):

2. Amount of CMA/SM Check: $

, for Period:

3. Payment Combined with Other Benefit
YES

NO

H. Date of Birth
1. Date of Birth and Proof Code on MBR Printout:
2. Evidence/Documentation in Claims Folder/MCS Screens:

3. Evidence Needing Verification:
4. Date of Birth Established by Desk Review:
I. Parent's Relationship
1. Type:
2. Support Period:
3. Parent's Income:
4. NH's Contributions:

5. 1/2 Support Determination in Claims Folder
YES

NO

6. Evidence Documentation in Claims Folder/MCS Screens:

7. Evidence Needing Verification:
Form SSA-2932-BK (11-1992) EF 11-2000

Page 4 of 10

FIELD/TELEPHONE REVIEW
II. PARENT
E. Recovery of Prior O/P in SM/Review Period
Beneficiary Agrees With DR Summary

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

Beneficiary Disagrees With DR Summary
(Explain)

F. Prior Underpayment on Sampled SSN

F. Prior U/P 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

H. Date of Birth

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

Evidence Obtained in Field Review:

I. Parent's Relationship

I. Parent's Relationship

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

Evidence Obtained in Field Review:

Form SSA-2932-BK (11-1992) EF 11-2000

Page 5 of 10

DESK REVIEW
II. PARENT
J. Marital History of Parent
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:
4. Is the parent's spouse a title II beneficiary?
YES (Spouse's SSN:
Form SSA-2932-BK (11-1992) EF 11-2000

)

NO
Page 6 of 10

FIELD/TELEPHONE REVIEW
II. PARENT
J. Marital History of Parent
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:

Form SSA-2932-BK (11-1992) EF 11-2000

Page 7 of 10

DESK REVIEW
II. PARENT
K. SMI Determination

NOT APPLICABLE

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

NO (Explain)

L. Misinformation/Contact With SSA Prior to Date Claim Filed
Would it have been to the beneficiary's advantage to file for benefits at an earlier date?
YES (Explain)

NO

M. Criminal Activities
Parent Beneficiary Not Involved in Any Criminal Activities Listed Below
Homicide of NH

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

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

Form SSA-2932-BK (11-1992) EF 11-2000

NO

Page 8 of 10

FIELD/TELEPHONE REVIEW
Consolidated Review

II. PARENT
K. SMI Determination

K. SMI Determination

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

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

L. Misinformation/Contact With
SSA Prior to DCF

If II.L. of the desk review summary is answered YES, did the
beneficiary inquire about filing at an earlier time but did not file because
of misinformation provided by SSA?
(Explain)

M. Criminal Activities

M. Criminal Activities
If any of the criminal activities listed in II.M. of the desk review
summary are involved, discuss and resolve below.

N. Representative Payee

N. Representative Payee

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

Form SSA-2932-BK (11-1992) EF 11-2000

NO

Page 9 of 10

CASE SUMMARY
II. PARENT
O. 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.
Section A

Section B

Section C

Section D

Section E

Section F

Section G

Section H

Section I

Section J

Section K

Section L

Section M

Section N

Additional Development/Findings/Remarks:

Signature of Reviewer(s):

Date:
Desk Reviewer
Date:
Field Reviewer
Date:
Consolidated Reviewer

Form SSA-2932-BK (11-1992) EF 11-2000

Page 10 of 10

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 20
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.