Form SSA-2931 RSI/DI Quality Review Case Analysis - Auxiliaries/Surviv

Form Approved
OMB No. 0960-0189

SOCIAL SECURITY ADMINISTRATION

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 progra m 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.
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 only comments
relating to our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

I. 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:

Face-to-Face

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)
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DESK REVIEW
II. 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)

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NO

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FACE-TO-FACE/TELEPHONE REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER
A. Number Holder Information
Deceased NH

Consolidated Review
A. Number Holder Information

Nonsampled NH

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

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

E. Eligible Children

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

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DESK REVIEW
II. 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:

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FACE-TO-FACE/TELEPHONE REVIEW
II. 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:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:

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DESK REVIEW
II. DECEASED/NONSAMPLED NUMBER HOLDER
G. Computation Information
Explanation

1. Work Issues
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

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
a. PPD Shown on MBR:

YES

NO

NONE

Date of Onset:

Term Date:

b. Documentation in File:
c. PPD Established by Desk Review:

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Date of Onset:

Term Date:

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FACE-TO-FACE/TELEPHONE REVIEW
II. 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

4. Prior Period(s) of Disability

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

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DESK REVIEW
Spouse

III. SPOUSE/SURVIVING SPOUSE/PARENT

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

Lawfully-Present Alien

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:

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FACE-TO-FACE/TELEPHONE REVIEW
III. 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/SSN’s

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

C. Date of Birth and Citizenship/Alien Status

C. DOB and Citizenship/Alien

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

Evidence Obtained in Field Review:

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DESK REVIEW
III. 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

F. Potential Entitlement on Own SSN:

NO

Not in Scope of Review
NOT APPLICABLE (Go to III.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

2. Unadjudicated Claims Issues:

NONE APPLY

Unprocessed Application

Deemed Filing

Protective Filing

Open Application

Partial Adjudication

Other Potential Entitlement (Leads)

Delayed Claim

Misinformation

(Explain)

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FACE-TO-FACE/TELEPHONE REVIEW
III. 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

G. Other Claims Activity

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

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DESK REVIEW
III. 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:

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FACE-TO-FACE/TELEPHONE REVIEW
III. 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:

g. Date Terminated:

h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:

NOTE: For Parent Review continue at Part V on page 30

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III. 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 (Go to III.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: $

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:

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FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE
I. Government Pension Offset

Consolidated Review
I. GPO

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

Evidence Obtained in Field Review:

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DESK REVIEW
III. SPOUSE/SURVIVING SPOUSE
J. Child-in-Care

NOT APPLICABLE (Go to III.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 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 Beneficiary

c. Nature and Frequency of Personal Services:

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

4. Evidence Needing Verification:

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FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE
J. Child-In-Care

Consolidated Review
NOT APPLICABLE

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
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 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
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

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Child

Other

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DESK REVIEW
III. SPOUSE/SURVIVING SPOUSE
K. Current DWB or Deemed DWB Entitlement

NOT APPLICABLE (Go to IV.)

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

Explanation

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:

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FACE-TO-FACE/TELEPHONE REVIEW
III. SPOUSE/SURVIVING SPOUSE

Consolidated Review

K. Current DWB or Deemed DWB Entitlement

K. Current DWB 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 Information

2. Disability-Related Work Info

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

Evidence Obtained in Field Review:

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DESK REVIEW
IV. 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(s)

(Explain)

2. Unadjudicated Claims Issues: BIC(s):

NO

NONE APPLY

Unprocessed Application

Deemed Filing

Delayed Claim

Protective Filing

Open Application

Misinformation

Partial Adjudication

Potential Entitlement on Another Parent’s SSN

Explain:

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FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD

Consolidated Review

A. Identity
1. BIC

A. Identity
2. Existence Verified By

3. SSN Verified By

B. Application

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

D. Other Claims Activity

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

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DESK REVIEW
IV. 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

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:

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FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
E. Date of Birth and Citizenship/Alien Status

Consolidated Review
E. DOB and Citizenship/Alien

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

Evidence Obtained in Field Review:

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DESK REVIEW
IV. 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

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 Number Holder:
c. Deemed Dependency:

YES (Go to d.)

Dependency Requirement(s) that Applies:

NO

YES

NO

Support Period:

Living With

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 Number Holder:
c. Deemed Dependency:

YES (Go to d.)

Dependency Requirement(s) that Applies:

NO

YES

NO

Support Period:

Living With

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 Number Holder:
c. Deemed Dependency:

YES (Go to d.)

Dependency Requirement(s) that Applies:

NO

YES

NO

Support Period:

Living With

Contributions

½ Support

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

e. Evidence Needing Verification:

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FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
F. Relationship and Dependency

Consolidated Review
F. Relationship and Dependency

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

Evidence Obtained in Field Review:

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DESK REVIEW
IV. 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:

YES

NO

H. School Attendance

(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

(If NO, Explain)
4. School is “Educational Institution”:

YES

NO

YES

NO

(If NO, Explain)
5. Student Beneficiary Paid by Employer:
(If YES, Explain)
6. Evidence/Documentation in Claims Folder/MCS Screens:

7. Evidence Needing Verification:

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FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
G. Marriage

Consolidated Review
G. Marriage

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

Evidence Obtained in Field Review:

H. School Attendance

H. School Attendance

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

Evidence Obtained in Field Review:

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DESK REVIEW
IV. CHILD
I. Current DAC Entitlement

NOT APPLICABLE (Go to VI.)

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

(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 File:
d. Evidence Needing Verification:
3. Potential Entitlement on Own SSN:

CURRENTLY ENTITLED (Go to VI.)

Wages
Self-Employment
Lag Wages/SEI
Gaps
Other
Insured Status Met

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FACE-TO-FACE/TELEPHONE REVIEW
IV. CHILD
I. Current DAC Entitlement

Consolidated Review
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 Information

2. Disability-Related Work Info

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

Evidence Obtained in Field Review:

3. Potential Entitlement on Own SSN

3. Potential Entitlement

Beneficiary Agrees With DR Summary

Beneficiary Disagrees With DR Summary:
Year

Amount on E/R

Amount Alleged

Evidence Obtained in Field Review:

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DESK REVIEW
V. 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

(Explain)
3. One-Half Support Met:
(Explain)

4. Evidence/Documentation of Support 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:

YES

YES (Complete Below)

NO

NO

b. If Yes, Spouse’s Claim Number:
2. Beneficiary Entitled to RIB Equal to/Exceeds Parent Original Benefit Amount:

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YES

NO

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FACE-TO-FACE/TELEPHONE REVIEW
V. 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

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VI. 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)

C. SMI Determination

NO

NOT APPLICABLE

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

NO

6. Check Amount Affected by Other Withholding (e.g., Medicare C/D Premiums,
Voluntary Tax Withholding, Garnishment, Treasury Offset Program, etc.):
YES (Explain)

NO

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FACE-TO-FACE/TELEPHONE REVIEW
VI. 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

D. Payment Amount

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

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DESK REVIEW
VII. 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

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:

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

(Explain)

BIC

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FACE-TO-FACE/TELEPHONE REVIEW
VII. 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 VI.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

(Explain)

BIC

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CASE SUMMARY
VII. 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:

II.A.

II.B.

II.C.

II.D.

II.E.

II.F.

II.G.

Spouse/Parent:

III.A.

III.B.

III.C.

III.D.

III.E.

III.F.

III.G.

IV.D.

IV.E.

IV.F.

IV.G.

III.H.
Spouse:

III.I.

III.J.

III.K.

Child:

IV.A

IV.B.

IV.C.

IV.H.

IV.I.

Parent:

V.A.

V.B.

V.C.

Payment for SM:

VI.A.

VI.B.

VI.C.

Additional Issues:

VII.A.

VII.B.

VII.C.

VI.D.

Additional Development/Findings/Remarks:

Signature of Reviewer(s):
Date:
Desk Reviewer
Date:
Field Reviewer
Date:
Consolidated Reviewer

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Form SSA-2931-BK (11-2014) EF (11-2014)
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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:
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 manager 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.

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