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 QR ANALYST: In opening the interview, explain that their case is one of a small number selected by chance for
review, and that the purpose of doing this review is to find out how well the Social Security program is working. Advise 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, explain that the Social Security Administration is authorized by law
to review the entitlement of beneficiaries from time to time.
Paperwork Reduction Act Statement - 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. 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, NON-SERVICE MONTHS, AND SWP
1. MBR Annual Report Information
Closed Year

Earnings Amount

Non-Service Months

LMETY

2. Closed Year Posted Earnings Posted to the SEQY/DEQY
Covered Earnings

Non-covered 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 on 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, did the NH provide AET information or were earnings posted by the later
of either April 30 of the sampled year or the last day of the sample month?
Yes

No

4. If Yes, did SSA process AET information by the later of either April 30 of the
sampled year or the last day of the sample month?

No

Form SSA-4659 (07/2011) EF (07-2011)
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Yes

PHONE REVIEW
Date of Beneficiary Contact:
PART I - CLOSED YEAR EARNINGS, NON-SERVICE MONTHS AND SWP

1. Wages - List beneficiary's employment allegations for the two years before the closed year

through the date of the interview. (Obtain 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

Years(s)
Employed

Address

Amount of Earnings
Closed Year
Subsequent Year

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

Form SSA-4659 (07/2011) EF (07-2011)
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PHONE REVIEW
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, obtain evidence showing the amount, date of payment, and type of
payment.)
Employer/Payer

Amount Received

Type of Payment

Date Received

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, obtain evidence of wage NSMs from
the beneficiary or the employer. If SE, obtain the contact information (including the name, phone number, and
address) of any individuals with information in reference to the SE and contact them for verification.)
Months

Wages

SE

Months

Wages

SE

Months

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?
2. If yes, when?
CONSOLIDATED REVIEW
Resolve any differences between desk review and field review findings:

Form SSA-4659 (07/2011) EF (07-2011)
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Wages

Yes

SE

No

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 either April 30
of the sampled 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 that affect payment for the closed year, summarize
below, code the error, and prepare the SSA-93 for corrective action.

REVIEWER’S SIGNATURE

Form SSA-4659 (07/2011) EF (07-2011)
Destroy all prior editions

DATE

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