SSA-2931 - Current

Form SSA-2931 (03-2018)
Discontinue Prior Editions
Social Security Administration

Page 1 of 37
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. SIC:

B. NH's SSN:

C. Sample Month Date:

D. Review Amount: $

E. Review Amount Determined by QR: $
F. Explanation of Changes, if Any:
G. Type of Interview

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:

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)

Page 2 of 37
DESK REVIEW

2. 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)

NO

Form SSA-2931 (03-2018)

Page 3 of 37
TELEPHONE REVIEW

2. DECEASED/NONSAMPLED NUMBER HOLDER

A. Number Holder Information

A. Number Holder Information
Deceased NH

Consolidated Review

Nonsampled NH
B. Other Names/SSNs

B. Other Names and SSNs Used
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

NOT APPLICABLE

Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary:
(Explain)

E. Eligible Children

Form SSA-2931 (03-2018)

Page 4 of 37
DESK REVIEW

2. 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 (03-2018)

Page 5 of 37
TELEPHONE REVIEW

2. 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:
h. Place Terminated:
i. Evidence Obtained:

Consolidated Review

g. Date Terminated:

Form SSA-2931 (03-2018)

Page 6 of 37
DESK REVIEW

2. DECEASED/NONSAMPLED NUMBER HOLDER
G. Computation Information
1. Work Issues

Explanation

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

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

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:

Form SSA-2931 (03-2018)

Page 7 of 37
TELEPHONE REVIEW

2. 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
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary:
(Explain)

4. Prior Period(s) of Disability

Form SSA-2931 (03-2018)

Page 8 of 37
DESK REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT

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

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:

Lawfully-Present Alien

Form SSA-2931 (03-2018)

Page 9 of 37
TELEPHONE REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT
A. Identity

Spouse

Consolidated Review
Parent

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/SSNs:

Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary:
(Explain)

C. Date of Birth and Citizenship/Alien Status
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary:
(Explain)

Evidence Obtained in Field Review:

C. DOB and Citizenship/Alien

Form SSA-2931 (03-2018)

Page 10 of 37
DESK REVIEW

3. 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)

1. Claim Number on

Non-sampled

Sampled SSN

2. Scope of Review

Non-sampled

Sampled SSN

Full Review

Limited Review

NO

Not in Scope of Review

F. Potential Entitlement on Own SSN:

NOT APPLICABLE (Go to 3.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

(Explain)

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 (03-2018)

Page 11 of 37
TELEPHONE REVIEW

3. 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
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary:
(Explain)

G. Other Claims Activity

Form SSA-2931 (03-2018)

Page 12 of 37
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)

Page 13 of 37
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)

Page 14 of 37
DESK REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT
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 3.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: $
c. Amount of Offset in Sample Month: $
d. Monthly Benefit After Offset: $
7. Evidence/Documentation in Claims Folder/MCS Screens:

8. Evidence Needing Verification:

b. Frequency of Payment:

Form SSA-2931 (03-2018)

Page 15 of 37
TELEPHONE REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT
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)

Page 16 of 37
DESK REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT
J. Child-in-Care (CIC)

NOT APPLICABLE (Go to 3.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 the 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 the Beneficiary

c. Nature and Frequency of Personal Services:

7. Evidence/Documentation in Claims Folder/MCS Screens:

8. Evidence Needing Verification:

Form SSA-2931 (03-2018)

Page 17 of 37
TELEPHONE REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT
J. Child-in-Care

Consolidated Review
J. Child-in-Care

NOT APPLICABLE

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 with 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

Child

Other

Form SSA-2931 (03-2018)

Page 18 of 37
DESK REVIEW

3. SPOUSE/SURVIVING SPOUSE/PARENT
K. Current DWB or Deemed DWB Entitlement

NOT APPLICABLE (Go to 4.)

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
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/PARENT
K. Current DWB or Deemed DWB Entitlement
1. Period(s) of Disability

Consolidated Review
K. Current DWB Entitlement
1. Period(s) of Disability

Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

2. Disability-Related Work Information
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

Evidence Obtained in Field Review:

2. Disability-Related Work Info

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. 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

)

NO

(Explain)

2. Unadjudicated Claims Issues: BIC(s):

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 (03-2018)

Page 21 of 37
TELEPHONE REVIEW

4. CHILD

Consolidated Review
A. Identity

A. Identity
1. BIC

2. Existence Verified By

B. Application

3. SSN Verified By

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
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

D. Other Claims Activity

Form SSA-2931 (03-2018)

Page 22 of 37
DESK REVIEW

4. 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

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:

FN:
Lawfully-Present Alien

Form SSA-2931 (03-2018)

Page 23 of 37
TELEPHONE REVIEW

4. CHILD

Consolidated Review

E. Date of Birth and Citizenship/Alien Status
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

Evidence Obtained in Field Review:

E. DOB and Citizenship/Alien

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 Number Holder:
c. Deemed Dependency:

YES (Go to d.)

Dependency Requirement(s) that Applies:

NO

YES

NO

Support Period:

Living With

Contributions

1/2 Support

d. Evidence/Documentation 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

1/2 Support

d. Evidence/Documentation 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

1/2 Support

d. Evidence/Documentation 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

e. Evidence Needing Verification:

NO

Support Period:

Living With

d. Evidence/Documentation in Claims Folder/MCS Screens:

YES

Contributions

1/2 Support

Form SSA-2931 (03-2018)

Page 25 of 37
TELEPHONE REVIEW

4. CHILD

Consolidated Review

F. Relationship and Dependency
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

Evidence Obtained in Field 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:

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:
H. School Attendance

YES

NO

(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

YES

NO

YES

NO

(If No, Explain)

4. School is "Educational Institution":
(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 (03-2018)

Page 27 of 37
TELEPHONE REVIEW

4. CHILD

Consolidated Review

G. Marriage

G. Marriage

Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

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

NOT APPLICABLE (Go to 6.)

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

YES (Explain)

NO

(Explain)

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 Claims Folder/MCS Screens:

d. Evidence Needing Verification:

3. Potential Entitlement on Own SSN:
Wages
Self-Employment
Lag Wages/SEI
Gaps
Other
Insured Status Met

CURRENTLY ENTITLED (Go to 6.)

Form SSA-2931 (03-2018)

Page 29 of 37
TELEPHONE REVIEW

4. 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 Info

2. Disability-Related Work Information
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

Evidence Obtained in Field Review:

3. Potential Entitlement

3. Potential Entitlement on Own SSN
Beneficiary Agrees with DR Summary

Beneficiary Disagrees with DR Summary
Year

Amount on E/R

Evidence Obtained in Field Review:

Amount Alleged

Form SSA-2931 (03-2018)

Page 30 of 37
DESK REVIEW

5. PARENT
A. 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:

B. One-Half Support
1. Support Period
2. Proof of Support Filed Timely:

YES

NO

YES

NO

YES (Complete Below)

NO

YES

NO

YES

NO

(Explain)

3. One-Half Support Met:
(Explain)

4. Evidence/Documentation of Relationship in Claims Folder/MCS Screens:

5. Evidence Needing Verification:

C. Other
1. Beneficiary Married after Number Holder's Death:
a. Parent's Spouse is a Title II Beneficiary:
b. If Yes, Spouse's Claim Number:
2. Beneficiary Entitled to RIB Equal to/Exceeds Parent Original Benefit Amount:

Form SSA-2931 (03-2018)

Page 31 of 37
TELEPHONE REVIEW

5. PARENT
A. Relationship

Consolidated Review
A. Relationship

Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

Evidence Obtained in Field Review:

B. One-Half Support

B. One-Half Support

Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

Evidence Obtained in Field Review:

C. Other

C. Other
Beneficiary Agrees with DR Summary
Beneficiary Disagrees with DR Summary
(Explain)

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:

YES (Explain)

NO

B. Recovery of Overpayment in Sample Month:

YES (Explain)

NO

YES

NO (Explain)

C. SMI Determination

NOT APPLICABLE

The SMI determination, including the premium deduction and penalty
amounts (if any), is correct.

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 Premiums,
Voluntary Tax Withholding, Garnishment, Treasury Offset Program, etc):

YES (Explain)

NO

Form SSA-2931 (03-2018)

Page 33 of 37
TELEPHONE REVIEW

6. 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
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:

3. 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:

3. 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)

NO

BIC:

(Explain)

Form SSA-2931 (03-2018)

Page 35 of 37
TELEPHONE REVIEW

7. 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 6.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)

NO

BIC:

(Explain)

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.B.

3.C.

3.D.

3.E.

3.F.

3.G.

3.I.

3.J.

3.K.

4.A.

4.B.

4.C.

4.D.

4.E.

4.F.

4.G.

4.H.

4.I.

Parent:

5.A.

5.B.

5.C.

Payment for SM:

6.A.

6.B.

6.C.

Additional Issues:

7.A.

7.B.

7.C.

3.H.
Spouse:
Child:

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 37of 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. Offices are also listed under U. S. Government agencies
in your telephone directory or you may call Social Security at 1-800-772-1213 (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
relating to our time estimate to this address, not the completed form.