Current SSA-4659

Form SSA-4659 (05-2024) UF
Discontinue Prior Editions
Social Security Administration

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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.

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

Posted SWP

Countable AET Earnings

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

Non-covered 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?
2. Were earnings for the closed year available on SSA records?
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?
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

Yes

No

Yes

No

Yes

No

Form SSA-4659 (05-2024) UF

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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

Year(s)
Amount of Earnings
Employed 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

Form SSA-4659 (05-2024) UF

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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

January

May

September

February

June

October

March

July

November

April

August

December

Wages

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 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:

Form SSA-4659 (05-2024) UF

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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.

Paperwork Reduction Act - 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.