Form SSA-4659 Stewardship Annual Earnings Test Workbook

Form Approved
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