Form SSA-4659 Stewardship Annual Earnings Test Workbook

Form SSA-4659 (03-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 4
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 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 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, point out that the Social Security Administration is authorized by law to review
from time to time the entitlement of beneficiaries.
DESK REVIEW
PART I - CLOSED YEAR EARNINGS, NONSERVICE 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 - As shown on the SEQY/DEQY
Covered Earnings

Noncovered Earnings

Do the posted earnings and special wage payment (SWP) information from the DEQY for the closed year agree with the
Annual Report information from the MBR/Claims file?
No (If No, describe
the development
Yes
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, was AET information given or were the earnings on SSA
records by the later of April 30 of the sample year or the last day
of the sample month?

Yes

No

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

Yes

No

Form SSA-4659 (03-2018) UF

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FIELD REVIEW

Date of Beneficiary Contact:
PART I -- CLOSED YEAR EARNINGS, NSM AND SWP
1.

Wages -- List beneficiary's employment allegations for the two years before the closed year through the date of
the interview. (Get 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.)
Year(s)
Amount of Earnings
Employer Name
Address
Employed Closed Year
Subsequent Year

Was the beneficiary a corporate officer/related to a corporate officer of a close
Yes
No
or family corporation listed above?
(If Yes, complete an SSA-795 per QRM 8044. If applicable, get a copy of resignation from office and the corporate minutes
accepting the resignation. If a questionable retirement issue is still not resolved, get copies of tax returns and any other
available evidence.)
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.)
Date
Name & Address of Business
Type of Business Date Started
If Ended, Reason Ended
Ended

If business sold or transferred, give the name, address, and phone number of the present operator and relationship to
the beneficiary:
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, get evidence showing
the amount, date of payment, and type of payment.)
Employer/Payer

Amount Received

Type of Payment

Date Received

Form SSA-4659 (03-2018) UF

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FIELD REVIEW

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 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, get evidence of wage NSMs from the beneficiary or the employer. If SE, get the name/phone/address
of people with knowledge & 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
phone review
Resolve any differences between desk review & field

CASE SUMMARY
Countable AET Earnings Established by QR

If LEMETY is Closed Year, NSM Established by QR

Do the payment adjustments, if any, made by SSA through the later of April 30 of the sample 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 which affect payment for the closed year, summarize here, code the error, and prepare
the SSA-93 for corrective action.

REVIEWER'S SIGNATURE:

DATE:

Form SSA-4659 (03-2018) UF

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Privacy Act Statement
See Revised
Collection and Use of Personal InformationPrivacy Act
Statement

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; 60-0059, entitled Earnings Recording and Self-Employment Income 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 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.