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
     	     	     	     

Did 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? Yes No

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 closed year and subsequent year. 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	Address	Years(s) Employed	Amount of Earnings
			Closed Year	Subsequent Year
     	     	     	     		     
     	     	     	     		     
     	     	     	     		     
     	     	     	     		     
     	     	     	     		     

2. Self-Employment - List beneficiary's self-employment allegations for the closed year and subsequent year. 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
     	     	     	     	     
     	     	     	     	     

PHONE REVIEW

3. Special Wage/SEI Payments - List any special wage/SEI payments received by the beneficiary in 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 applies in the closed year, check the months the beneficiary earned wages under the AET monthly limit and/or 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	Wages	SE
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? Yes No

2. If yes, when?      

CONSOLIDATED REVIEW

Resolve any differences between desk review and phone review findings:

     

CASE SUMMARY

Countable AET Earnings Established by QR	If LMETY is Closed Year, NSM Established by QR
     	     

Did 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            

DATE      

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:

• 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; and

• To student volunteers, individuals working under a personal services contract, and other workers who technically do not have the status of Federal employees, when they are performing work for SSA as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned Agency functions

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, as published in the Federal Register (FR) on October 13 1982, at 47 FR 45606; 60-0059, entitled Earnings Recording and Self-Employment Income System as published in the FR on January 11, 2006, at 71 FR 1819; and 60-0090, entitled Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826. Additional information and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy.

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

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