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pdfForm SSA-2931 (03-2018)
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Social Security Administration
OMB No. 0960-0189
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 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 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.
1. IDENTIFYING AND REVIEW INFORMATION
A. Study ID Code:
B. NH’s SSN:
C. Sample Month:
D. Review Amount: $
E. Review Amount Determined by OQR: $
F. Explanation of Review Amount Changes, if OQR Determination is different:
G. Type of Interview:
Telephone
Other
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: (
)
2. Name/Address/Phone
3. Payee Name/Address/Phone
Name:
Name:
Address:
Address:
Phone: (
)
Phone: (
)
2. Name/Address/Phone
3. Payee Name/Address/Phone
Name:
Name:
Address:
Address:
Phone: (
)
Phone: (
)
2. Name/Address/Phone
3. Payee Name/Address/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 (03-2018)
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DESK REVIEW
2. DECEASED/NON-SAMPLED NUMBER HOLDER
A. Number Holder Information
Deceased NH
Non-sampled NH
B. Other Names and SSNs Shown in File/Numident
N/A
1. Other Names:
2. Other SSNs:
C. Date of Birth
1. Date of Birth and Proof Code on MBR:
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
N/A
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)
NO
Form SSA-2931 (03-2018)
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TELEPHONE REVIEW
2. DECEASED/NON-SAMPLED NUMBER HOLDER
A. Number Holder Information
Deceased NH
Consolidated Review
A. Number Holder Information
Non-sampled NH
B. Other Names and SSNs Used
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
B. Other Names/SSNs
C. Date of Birth
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
C. Date of Birth
Evidence Obtained in Field Review:
D. Date of Death
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
D. Date of Death
Evidence Obtained in Field Review:
E. Eligible Children
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
E. Eligible Children
Form SSA-2931 (03-2018)
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DESK REVIEW
2. DECEASED/NON-SAMPLED NUMBER HOLDER
F. Marital History of NH
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 (03-2018)
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TELEPHONE REVIEW
2. DECEASED/NON-SAMPLED NUMBER HOLDER
F. Marital History of NH
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:
h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:
g. Date Terminated:
Form SSA-2931 (03-2018)
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DESK REVIEW
2. DECEASED/NON-SAMPLED NUMBER HOLDER
G. Computation Information
1. Work Issues
Explanation
Wages
Self-Employment
Lag Wages/SEI
Gaps
Annual Reports
Duplicates/Incompletes
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
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 (PPD)
YES
NO
NONE
a. PPD Shown on MBR: Date of Onset:
Term Date:
b. Documentation in File:
c. PPD Established by Desk Review: Date of Onset:
Term Date:
NO
Form SSA-2931 (03-2018)
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TELEPHONE REVIEW
2. DECEASED/NON-SAMPLED NUMBER HOLDER
G. Computation Information
1. Work Issues
Beneficiary Agrees With DR Summary
Consolidated Review
G. Computation Information
1. Work Issues
Beneficiary Disagrees With DR Summary:
Explain:
Evidence Obtained in Field Review:
2. Military Service
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
2. Military Service
Evidence Obtained in Field Review:
3. Railroad Employment
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
3. RR Employment
4. Prior Period(s) of Disability
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
4. Prior Period(s) of Disability
Form SSA-2931 (03-2018)
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DESK REVIEW
3. SPOUSE/SURVIVING SPOUSE/PARENT
A. Identity
TELEPHONE
Spouse
Parent
OTHER
1. Name:
2. SSN (BOAN):
B. Other Names and SSNs Shown in Claims Folder/Numident
N/A
1. Other Names:
2. Other SSNs:
C. Date of Birth/U.S. Citizenship/Alien Status
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
5. Evidence/Documentation in Claims Folder/MCS Screens:
6. Evidence Needing Verification:
7. Date of Birth Established by Desk Review:
8. U.S. Citizenship/Alien Status Established by Desk Review:
Remarks:
Lawfully-Present Alien
Form SSA-2931 (03-2018)
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TELEPHONE REVIEW
3. SPOUSE/SURVIVING SPOUSE/PARENT
A. Identity
Spouse
Consolidated Review
Parent
A. Identity
1. Existence Verified by:
Telephone:
2. SSN Verified by:
SSN Card
Other:
Medicare Card
B. Other Names and SSNs Used
B. Other Names/SSN’s
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
C. Date of Birth and U.S. Citizenship/Alien Status
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
C. DOB and U.S. Citizenship/Alien
Form SSA-2931 (03-2018)
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DESK REVIEW
3. SPOUSE/SURVIVING SPOUSE/PARENT
D. Application
1. Date Claim Filed:
2. MOE and MOEL Option Code:
3. MOE Determined by Desk Review:
E. Multiple Entitlement Involved:
YES (Complete Below)
NO
1. Claim Number on
Non-sampled
Sampled SSN
2. Scope of Review
Full Review
Non-sampled
Limited Review
Sampled SSN
Not in Scope of Review
F. Potential Entitlement on Own SSN:
N/A
Wages
Self-Employment
Lag Wages/SEI
Gaps
Duplicates/Incompletes
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
(Explain)
2. Unadjudicated Claims Issues:
Unprocessed Application
Protective Filing
Partial Adjudication
Delayed Claim
(Explain)
NONE APPLY
Deemed Filing
Open Application
Other Potential Entitlement (Leads)
Misinformation
Form SSA-2931 (03-2018)
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TELEPHONE REVIEW
3. SPOUSE/SURVIVING SPOUSE/PARENT
Consolidated Review
D. Application
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
D. Application
E. Multiple Entitlement
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
E. Multiple Entitlement
F. Potential Entitlement on Own SSN
Beneficiary Agrees With DR Summary
N/A
F. Potential Entitlement
Beneficiary Disagrees With DR Summary
Explain:
Evidence Obtained in Field Review:
G. Other Claims Activity
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
G. Other Claims Activity
Form SSA-2931 (03-2018)
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DESK REVIEW
3. 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 (03-2018)
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TELEPHONE REVIEW
3. 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:
h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:
NOTE: For Parent Review continue at Part 5 on page 30
g. Date Terminated:
Form SSA-2931 (03-2018)
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DESK REVIEW
3. 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
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)
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 No Exemptions for GPO Apply, Enter Pension Information:
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 (03-2018)
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TELEPHONE REVIEW
3. SPOUSE/SURVIVING SPOUSE
I. Government Pension Offset
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
Consolidated Review
I. GPO
Form SSA-2931 (03-2018)
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DESK REVIEW
3. SPOUSE/SURVIVING SPOUSE
J. Child-in-Care (CIC)
N/A
COMPLETE TO ESTABLISH CHILD IS IN THE BENEFICIARY’S CARE
1. Child-in-Care Under Age 16 or Mentally Disabled, Beneficiary Exercises Parental Control
YES (Complete Below)
NO
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
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 (03-2018)
Page 17 of 37
TELEPHONE REVIEW
3. SPOUSE/SURVIVING SPOUSE
J. Child-In-Care
Consolidated Review
N/A
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
Phone Verification
Other
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
Phone Verification
Other
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
Child
Other
Form SSA-2931 (03-2018)
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DESK REVIEW
3. SPOUSE/SURVIVING SPOUSE
K. Current DWB or Deemed DWB Entitlement
N/A
1. Period(s) of Disability
a. Established Onset Date:
c. Disabled Before End of Prescribed Period:
b. Date of Entitlement:
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
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:
Explanation
Form SSA-2931 (03-2018)
Page 19 of 37
TELEPHONE REVIEW
3. SPOUSE/SURVIVING SPOUSE
K. Current DWB or Deemed DWB Entitlement
Consolidated Review
K. Current DWB Entitlement
1. Period(s) of Disability
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
1. Period(s) of Disability
2. Disability-Related Work Information
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
2. Disability-Related Work Info
Evidence Obtained in Field Review:
Form SSA-2931 (03-2018)
Page 20 of 37
DESK REVIEW
4. CHILD
A. Identity
1. BIC
2. Name
3. SSN (BOAN)
B. Application
1. BIC
2. Type of Benefit
3. Date Claim Filed
4. Month of
Entitlement
5. Month of Entitlement Determined by Desk Review
BIC
MOE
BIC
MOE
BIC
MOE
BIC
MOE
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
NO
(Explain)
2. Unadjudicated Claims Issues: BIC(s):
Unprocessed Application
Protective Filing
Partial Adjudication
Explain:
NONE APPLY
Deemed Filing
Delayed Claim
Open Application
Misinformation
Potential Entitlement on Another Parent’s SSN
Form SSA-2931 (03-2018)
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TELEPHONE REVIEW
4. CHILD
Consolidated Review
A. Identity
1. BIC
A. Identity
2. Existence Verified By
3. SSN Verified By
B. Application
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
B. Application
C. Multiple Entitlement
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
C Multiple Entitlement
D. Other Claims Activity
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
D. Other Claims Activity
Form SSA-2931 (03-2018)
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DESK REVIEW
4. CHILD
E. Date of Birth
1. BIC:
a. Date of Birth and Proof Code on MBR Printout:
b. Place of Birth:
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. U.S. Citizenship/Alien Status Established by Desk Review:
2. BIC:
a. Date of Birth and Proof Code on MBR Printout:
b. Place of Birth:
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. U.S. Citizenship/Alien Status Established by Desk Review:
3. BIC:
a. Date of Birth and Proof Code on MBR Printout:
b. Place of Birth:
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. U.S. 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:
MN:
U.S. Citizen/National
d. Evidence/Documentation in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
f. Date of Birth Established by Desk Review:
g. U.S. Citizenship/Alien Status Established by Desk Review:
FN:
Lawfully-Present Alien
Form SSA-2931 (03-2018)
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TELEPHONE REVIEW
4. CHILD
E. Date of Birth and U.S. Citizenship/Alien Status
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
Consolidated Review
E. DOB and U.S. Citizenship/Alien
Status
Form SSA-2931 (03-2018)
Page 24 of 37
DESK REVIEW
4. CHILD
F. Relationship and Dependency
1. BIC:
a. Type of Child Relationship:
b. Child Adopted or Equitably Adopted by Someone other than NH:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
Living With
YES
NO
Support Period:
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 NH:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
Living With
YES
NO
Support Period:
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 NH:
c. Deemed Dependency:
YES (Go to d.)
Dependency Requirement(s) that Applies:
NO
Living With
YES
NO
Support Period:
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 NH:
c. Deemed Dependency:
YES (Complete d.)
Dependency Requirement(s) that Applies:
Living With
YES
NO
NO Support Period:
Contributions
½ Support
d. Evidence/Documentation of Relationship/Dependency in Claims Folder/MCS Screens:
e. Evidence Needing Verification:
Form SSA-2931 (03-2018)
Page 25 of 37
TELEPHONE REVIEW
4. CHILD
F. Relationship and Dependency
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
Consolidated Review
F. Relationship and Dependency
Form SSA-2931 (03-2018)
Page 26 of 37
DESK REVIEW
4. CHILD
G. Marriage
1. Has any child beneficiary ever been married?
a. BIC:
b. Current/Last Marriage to:
YES (Complete Below)
c. Age/Date of Birth:
e. Date of Marriage:
g. Place of Marriage:
h. How Terminated:
j. Place Terminated:
k. Evidence/Documentation in Claims Folder/MCS Screens:
NO
d. SSN:
f. Type:
i. Date Terminated:
l. Evidence Needing Verification:
2. Child’s spouse is a Title II Beneficiary:
YES
NO
H. School Attendance
1. BIC(s):
2. Name and Address of School:
(If Yes, Claim Number):
N/A
3. Full-Time Attendance or Deemed Full-Time Attendance in Sample Month:
(If NO, Explain)
4. School is “Educational Institution”:
YES
NO
(If NO, Explain)
5. Student Beneficiary Paid by Employer:
(If YES, Explain)
YES
NO
6. Evidence/Documentation in Claims Folder/MCS Screens:
7. Evidence Needing Verification:
YES
NO
Form SSA-2931 (03-2018)
Page 27 of 37
TELEPHONE REVIEW
4. CHILD
G. Marriage
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Consolidated Review
G. Marriage
Evidence Obtained in Field Review:
H. School Attendance
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Evidence Obtained in Field Review:
H. School Attendance
Form SSA-2931 (03-2018)
Page 28 of 37
DESK REVIEW
4. CHILD
I. Current DAC Entitlement
N/A
1. Period(s) of Disability?
a. BIC(s):
b. Established Onset Date:
c. Disabled before Age 22 or Re-Entitled & Disabled Within Applicable Timeframe:
(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 Claims Folder/MCS Screens:
d. Evidence Needing Verification:
3. Potential Entitlement on Own SSN:
Wages
Self-Employment
Lag Wages/SEI
Gaps
Duplicates/Incompletes
Other
Insured Status Met
CURRENTLY ENTITLED
YES
NO
Form SSA-2931 (03-2018)
Page 29 of 37
TELEPHONE REVIEW
4. CHILD
I. Current DAC Entitlement
Consolidated Review
I. Current DAC Entitlement
1. Period(s) of Disability
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
1. Period(s) of Disability
2. Disability-Related Work Information
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary
(Explain)
2. Disability-Related Work Info
Evidence Obtained in Field Review:
3. Potential Entitlement on Own SSN
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
Explain:
Evidence Obtained in Field Review:
3. Potential Entitlement
Form SSA-2931 (03-2018)
Page 30 of 37
DESK REVIEW
5. PARENT
A. Relationship
1. Type of Parent Relationship:
Natural Parent
Step-Parent
Adoptive Parent
2. Evidence/Documentation of Relationship in Claims Folder/MCS Screens:
3. Evidence Needing Verification:
B. One-Half Support
1. Support Period:
2. Proof of Support Filed Timely:
(Explain)
YES
NO
3. One-Half Support Met:
(Explain)
YES
NO
4. Evidence/Documentation of Support in Claims Folder/MCS Screens:
5. Evidence Needing Verification:
C. Other
1. Beneficiary Married after NH’s Death:
a. Parent’s Spouse is a Title II Beneficiary:
YES
NO
YES
NO
b. If Yes, Spouse’s Claim Number:
2. Beneficiary Entitled to RIB Equal to/Exceeds Parent Original Benefit Amount:
YES
NO
Form SSA-2931 (03-2018)
Page 31 of 37
TELEPHONE REVIEW
5. PARENT
A. Relationship
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
Consolidated Review
A. Relationship
Evidence Obtained in Field Review:
B. One-Half Support
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
B. One-Half Support
Evidence Obtained in Field Review:
C. Other
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
C. Other
Form SSA-2931 (03-2018)
Page 32 of 37
DESK REVIEW
6. PAYMENT FOR THE SAMPLE MONTH
A. Underpayment on Sampled SSN Needed to Be Addressed:
B. Recovery of Overpayment in Sample Month:
N/A
N/A
YES (Explain)
NO
YES (Explain)
NO
C. SMI Determination
The SMI determination (including the premium deduction and any penalty amounts) is correct.
N/A
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
6. Check Amount Affected by Withholding/Deductions (e.g., Medicare Premiums,
Voluntary Tax Withholding, Alien Tax, Garnishment, Treasury Offset Program, etc.):
NO
YES (Explain)
NO
Form SSA-2931 (03-2018)
Page 33 of 37
TELEPHONE REVIEW
6. PAYMENT FOR THE SAMPLE MONTH
Consolidated Review
A. Underpayment on Sampled SSN
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
A. Underpayment
B. Recovery of Overpayment in Sample Month
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
B. Overpayment
C. SMI Determination
N/A
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
C. SMI Determination
D. Payment Amount
Beneficiary Agrees With DR Summary
Beneficiary Disagrees With DR Summary:
(Explain)
D. Payment Amount
Form SSA-2931 (03-2018)
Page 34 of 37
DESK REVIEW
7. 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:
BICs:
Not Involved in Criminal Activities Listed Below
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 desk review indicate that an unresolved representative payee issue
exists (need for payee change, etc.) for a sampled beneficiary(ies)?
YES BIC:
(Explain)
NO BIC:
(Explain)
Form SSA-2931 (03-2018)
Page 35 of 37
TELEPHONE REVIEW
7. ADDITIONAL ISSUES
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)
Consolidated Review
A. Fugitive Felon
Evidence Obtained in Field Review:
B. Criminal Activities
If any of the criminal activities listed in 7.B of the desk review summary are
involved, discuss and resolve below.
B. Criminal Activities
C. Representative Payee
There is an indication that an unresolved representative payee issue
exists (need for payee change, etc.) for a sampled beneficiary(ies).
YES BIC:
(Explain)
NO BIC:
(Explain)
C. Representative Payee.
Form SSA-2931 (03-2018)
Page 36 of 37
CASE SUMMARY
7. 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:
2.A.
2.B.
2.C.
2.D.
2.E.
2.F.
2.G.
Spouse/Parent:
3.A.
3.H.
3.B.
3.C.
3.D.
3.E.
3.F.
3.G.
Spouse:
3.I.
3.J.
3.K.
Child:
4.A.
4.H.
4.B.
4.I.
4.C.
4.D.
4.E.
4.F.
4.G.
Parent:
5.A.
5.B.
5.C.
Payment for SM:
6.A.
6.B.
6.C.
Additional Issues:
7.A.
7.B.
7.C.
6.D.
Additional Development/Findings/Remarks:
Signature of Reviewer(s):
Desk Reviewer
Date:
Field Reviewer
Date:
Consolidated Reviewer
Date:
Form SSA-2931 (03-2018)
Page 37 of 37
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 228(a), 1614(a) and 1836 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from
verifying your eligibility for benefits.
We will use the information to check data for accuracy and to verify documentation used to establish your eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to
the individual's capability to manage their affairs or eligibility for or entitlement to benefits under the Social Security
program when the data are needed to establish the validity of evidence or to verify the accuracy of information
presented by the individual; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs. We will disclose information under the routine use
only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in
accomplishing an agency function relating to this system of records
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared
with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or
delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0040, entitled
Quality Review System; and, 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all
our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
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 OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Office are also
listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-7721213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments on our time estimate to this address, not the completed form.
| File Type | application/pdf |
| Author | [email protected] |
| File Modified | 2020-10-05 |
| File Created | 2020-10-05 |