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OMB No. 0960-0189
SOCIAL SECURITY ADMINISTRATION
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 QR ANALYST: 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 may 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 10 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.
DESK REVIEW
PART I -- CLOSED YEAR EARNINGS, NONSERVICE MONTHS, AND SWP
1. MBR Annual Report Information
Closed Year
Earnings Amount
Nonservice Months
LMETY Year
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 INFORMATION
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
Form SSA-4659 (07-2011) EF (07-2011)
Destroy prior editions
Page 1
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 the subsequent year, unless the
DEQY agrees with the beneficiary's allegation. If earnings for closed year are significantly lower than the years
before and after, ask the reason for the decline.)
Employer Name
Year(s)
Employed
Address
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 the 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
Form SSA-4659 (07-2011) EF (07-2011)
Type of Payment
Page 2
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 the 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 and contact them for verification.)
Months
Wages
SE
Months
Wages
SE
Months
Wages
January
May
September
February
June
October
March
July
November
April
August
December
SE
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 & field review
CASE SUMMARY
Countable AET Earnings Established by QR
If LEMETY 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 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
Form SSA-4659 (07-2011) EF (07-2011)
DATE
Page 3
File Type | application/pdf |
File Title | Stewardship AET Workbook |
Subject | Form for interviewing a sample number holder for the AET as part of the Title II Stewardship Review. |
Author | SSA |
File Modified | 2011-08-03 |
File Created | 2011-07-21 |