Download:
pdf |
pdfForm Approved
OMB No. 0960-0189
SOCIAL SECURITY ADMINISTRATION
RSI/DI QUALITY REVIEW CASE ANALYSIS – AUXILIARY/SURVIVOR
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 progra m 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.
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 30 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.
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 1 of 36
DESK REVIEW
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
NO
Page 2 of 36
FACE-TO-FACE/TELEPHONE REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER
A. Number Holder Information
Deceased NH
Consolidated Review
A. Number Holder Information
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 3 of 36
DESK REVIEW
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 4 of 36
FACE-TO-FACE/TELEPHONE REVIEW
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 5 of 36
DESK REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER
G. Computation Information
Explanation
1. Work Issues
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?
4. Prior Period(s) of Disability
a. PPD Shown on MBR:
YES
NO
NONE
Date of Onset:
Term Date:
b. Documentation in File:
c. PPD Established by Desk Review:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Date of Onset:
Term Date:
Page 6 of 36
FACE-TO-FACE/TELEPHONE REVIEW
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 7 of 36
DESK REVIEW
III. SPOUSE/SURVIVING SPOUSE/PARENT
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:
4. Applications Filed 12/1/96 or Later:
FN:
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 8 of 36
FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE/PARENT
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 9 of 36
DESK REVIEW
III. SPOUSE/SURVIVING SPOUSE/PARENT
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 10 of 36
FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE/PARENT
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 11 of 36
DESK REVIEW
III. SPOUSE/SURVIVING SPOUSE/PARENT
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 12 of 36
FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE/PARENT
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:
NOTE: For Parent Review continue at Part V on page 30
Form SSA-2931(xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 13 of 36
DESK REVIEW
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 14 of 36
FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE
I. Government Pension Offset
Consolidated Review
I. GPO
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 15 of 36
DESK 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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 16 of 36
FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE
J. Child-In-Care
Consolidated Review
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 Not Observed in Home
Existence Verified by
Residence Verified by
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
Residence Verified by
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
Form SSA-2931-BK ((xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Child
Other
Page 17 of 36
DESK REVIEW
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)
YES (Complete Below)
NO
2. Disability-Related Work Information
a. Earnings After Current Established Onset Date:
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 18 of 36
FACE-TO-FACE/TELEPHONE REVIEW
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 19 of 36
DESK 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
)
(BIC
Claim Number
)
(BIC
Claim Number
)
(BIC
Claim Number
)
NO
D. Other Claims Activity
1. Did any child beneficiary ever file for any other benefits (including SSI)?
YES (BIC(s)
(Explain)
2. Unadjudicated Claims Issues: BIC(s):
NO
NONE APPLY
Unprocessed Application
Deemed Filing
Delayed Claim
Protective Filing
Open Application
Misinformation
Partial Adjudication
Potential Entitlement on Another Parent’s SSN
Explain:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 20 of 36
FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
Consolidated Review
A. Identity
1. BIC
A. Identity
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 21 of 36
DESK REVIEW
IV. CHILD
E. Date of Birth
1. BIC:
a. Date of Birth and Proof Code on MBR Printout:
b. Place of Birth:
c. MN:
c. Applications Filed 12/1/96 or Later:
U.S. Citizen/National
FN:
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:
c. Applications Filed 12/1/96 or Later:
U.S. Citizen/National
FN:
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:
c. Applications Filed 12/1/96 or Later:
U.S. Citizen/National
FN:
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. Applications Filed 12/1/96 or Later:
c. MN:
U.S. Citizen/National
FN:
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 22 of 36
FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
E. Date of Birth and Citizenship/Alien Status
Consolidated Review
E. DOB and Citizenship/Alien
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain
Evidence Obtained in Field Review:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 23 of 36
DESK 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:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
YES
NO
Support Period:
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:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
YES
NO
Support Period:
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:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
YES
NO
Support Period:
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:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
YES
NO
Support Period:
Living With
Contributions
½ Support
d. Evidence/Documentation of Relationship/Dependency in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 24 of 36
FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
F. Relationship and Dependency
Consolidated Review
F. Relationship and Dependency
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain
Evidence Obtained in Field Review:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 25 of 36
DESK REVIEW
IV. CHILD
G. Marriage
1. Has any child beneficiary ever been married?
a. BIC:
YES (Complete Below)
NO
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
H. School Attendance
(If Yes, Claim Number):
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
YES
NO
(If NO, Explain)
5. Student Beneficiary Paid by Employer:
(If YES, Explain)
6. Evidence/Documentation in Claims Folder/MCS Screens:
7. Evidence Needing Verification:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 26 of 36
FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
G. Marriage
Consolidated Review
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 27 of 36
DESK 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:
b. Disability-Related Work Issues
YES (Explain)
NO
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
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 28 of 36
FACE-TO-FACE/TELEPHONE REVIEW
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:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 29 of 36
DESK REVIEW
V. PARENT
Relationship
1. Type of Parent Relationship:
Natural Parent
Stepparent
Adoptive Parent
2. Evidence/Documentation of Relationship in Claims Folder/MCS Screens:
3. Evidence Needing Verification:
J. One-Half Support
1. Support Period:
2. Proof of Support Filed Timely:
YES
NO
YES
NO
(Explain)
3. One-Half Support Met:
(Explain)
4. Evidence/Documentation of Support in Claims Folder/MCS Screens:
5. Evidence Needing Verification:
K. Other
1. Beneficiary Married after Number Holder’s Death:
a. Parent’s Spouse is a Title II Beneficiary:
YES
YES (Complete Below)
NO
b. If Yes, Spouse’s Claim Number:
2. Beneficiary Entitled to RIB Equal to/Exceeds Parent Original Benefit Amount:
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
NO
YES
NO
Page 30 of 36
FACE–TO-FACE/TELEPHONE REVIEW
V. PARENT
I. Relationship
Consolidated Review
I. Relationship
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
J. One-Half Support
J. One-Half Support
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain
Evidence Obtained in Field Review:
K. Other
K. Other
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 31 of 36
DESK REVIEW
VI. 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)
C. SMI Determination
NO
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
NO
Page 32 of 36
FACE-TO-FACE/TELEPHONE REVIEW
VI. PAYMENT FOR THE SAMPLE MONTH
A. Underpayment on Sampled SSN
Consolidated Review
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)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 33 of 36
DESK REVIEW
VII. 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)
(BIC
Explain)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
NO
Page 34 of 36
FACE-TO-FACE/TELEPHONE REVIEW
VII. 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)
(BIC
Explain)
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
NO
Page 35 of 36
CASE SUMMARY
VII. 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/Parent:
III.A.
III.B.
III.C.
III.D.
III.E.
III.F.
III.G.
IV.D.
IV.E.
IV.F.
IV.G.
III.H.
Spouse:
III.I.
III.J.
III.K.
Child:
IV.A
IV.B.
IV.C.
IV.H.
III.I.
Parent:
V.A.
V.B.
V.C.
Payment for SM:
VI.A.
VI.B.
VI.C.
Additional Issues:
VII.A.
VII.B.
VII.C.
VI.D.
Additional Development/Findings/Remarks:
Signature of Reviewer(s):
Date:
Desk Reviewer
Date:
Field Reviewer
Date:
Consolidated Reviewer
Form SSA-2931-BK (xx-xxxx) EF (xx-xxxx)
Destroy All Prior Editions
Page 36 of 36
| File Type | application/pdf |
| File Title | Form Approved |
| Author | 144543 |
| File Modified | 2014-05-06 |
| File Created | 2014-05-06 |