Form SSA-4659 Stewardship Annual Earnings Test Workbook

Form Approved

SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0189

STEWARDSHIP AET WORKBOOK

NUMBER HOLDER’S NAME      	NUMBER HOLDER’S SSN      
BENEFICIARY’S NAME AND BIC      	X-REFERENCE CLAIM NUMBER      
SAMPLE MONTH AND YEAR      	CLOSED YEAR      

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

1. MBR Annual Report Information

Closed Year	Earnings Amount	Non-Service Months	LMETY
    	     	     	     

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 (If No, describe the development needed to resolve the discrepancy.)

PART II -- ANNUAL REPORT PROCESSING

1. Did the beneficiary file an annual report for the closed year? Yes No

2. Were earnings for the closed year 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? 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

FIELD REVIEW

Date of Beneficiary Contact:      

PART I -- CLOSED YEAR EARNINGS, NSM AND SWP

1. 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
			Closed Year	Subsequent Year
           	                 	           	    	    
           	                 	           	    	    
           	                 	           	    	    
           	                 	           	    	    
           	                 	           	    	    

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.)

2. 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
                 	           	     	     	                 
                 	           	     	     	                 

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

     

     

3. 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
                 	     	           	     
                 	     	           	     

FIELD REVIEW

4. 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	     	     	May	     	     	September	     	     
February	     	     	June	     	     	October	     	     
March	     	     	July	     	     	November	     	     
April	     	     	August	     	     	December	     	     

PART II -- ANNUAL REPORT INFORMATION

1. Did the beneficiary give AET information to SSA for the closed year? Yes No

2. 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
     	     

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            

DATE      

Form SSA-4659-F4 (XX-XXXX) (Formerly SSA-4659-BK)

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