Ssa-2930

Form Approved
OMB No. 0960-0189

SOCIAL SECURITY ADMINISTRATION

RSI/DI QUALITY REVIEW CASE ANALYSIS - SAMPLED NUMBER HOLDER
NOTE TO REVIEWER: In opening the interview, ask if the beneficiaries received an appointment letter. If the
letter was not received, show the beneficiaries a copy of the letter. Explain that this case is one of a small
number collected by chance for review, and that the purpose of this review is to find out how well the social
security program is working. Stress that this case was not selected because there was any question about it.
Tell them that the review consists of asking questions about their entitlement to social security benefits and
that we 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.
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 are not required to answer these questions unless we display a
valid Office of Management and Budget control number. We estimate that it will take you about 30 minutes to
read the instructions, gather the necessary facts, and answer the questions.

I. IDENTIFYING AND REVIEW INFORMATION
A. SIC:

B. NH's SSN:

C. Sample Selection Date (As Shown on SCL):
D. Review Amount on SCL: $
E. SSI Offset Involved in Determining the Sample Dollars

YES

NO

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

H. NH's Name (As Shown on MBR):
I. NH's Address/Phone
Address:

Phone:

(

)

J. Payee Name Address/Phone
Name:
Address:

Phone:

(

)

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER
A. Identity
Type of Interview
Face-to-Face

Telephone

Desk Review only

B. Other Names and Corresponding SSN's Shown in Claims Folder/Numident
1. Other Names:
2. Other SSNs:

C. Application
1. Date Claim Filed:
2. DOE and MOEL Option Code:
3. Was the NH previously entitled to benefits (including SSI) on this or any other SSN?

YES (Explain)

NO

4. Unresolved Claims Issues:

NONE APPLY

Unprocessed Application

Deemed Filing

Protective Filing

Open Application

Partial Adjudication

Potential Entitlement (Leads)

Delayed Claim

Totalization

Explain:

5. Month of Entitlement Determined by Desk Review:

D. Multiple Entitlement Involved
YES (Complete Below)

NO

1. Claim Number on Nonsampled SSN:
2. Scope of Review of Non sampled SSN:
Limited Review
Form SSA-2930-BK (07-2000) (EF 2-2002)
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Full Review
Not in Scope of Review
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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER

Consolidated Review

A. Identity (SAMPLED NUMBER HOLDER)

A. Identity

1. Existence Verified by:
Observation
2. SSN Verified by:

Other:
SS Card

Medicare Card

Other:

B. Other Names and SSN's Used in Reporting Earnings

B. Other Names/SSN's

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary
(Explain)

C. Application

C. Application

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary.
(Explain)

D. Multiple Entitlement Involved

D. Multiple Entitlement

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary.
(Explain)

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER
E. Recovery of Prior Overpayment in Sample Month/Review Period
YES (Complete Below)

NO

Total Amount of Overpayment:

$

F. Underpayment on Sampled SSN Needed to Be Addressed
YES (Explain)

NO

G. Payment Amount(s)
1. Amount of PMA Check: $
2. Amount of CMA/SM Check:

, for Period:
$

, for Period:

3. Payment Combined with Other Benefit
YES

NO

H. Date of Birth/Citizenship
1. Date of Birth and Proof Code on MBR Printout:
2. Place of Birth:
(a) Alien Status:

Yes

No

3. MN:

(b) If yes, develop per QRM-3766
FN:

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

5. Evidence Needing Verification:

6. Date of Birth Established by Desk Review:
Remarks:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER
E. Recovery of Overpayment in SM/Review Period
Number Holder Agrees With DR Summary

Consolidated Review
E. Recovery of
Overpayment in SM/Review
Period

Number Holder Disagrees With DR Summary
(Explain)

F. Underpayment on Sampled SSN

F. Underpayment on Sampled
SSN

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary
(Explain)

G. Payment Amount(s)

G. Payment Amount(s)

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary
(Explain)

H. Date of Birth

H. Date of Birth

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary
(Explain)

Evidence Obtained in Field Review:

Development/Findings/Remarks:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER

NUMBER HOLDER NEVER MARRIED

I. Marital History of Sampled 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-2930-BK (07-2000) (EF 2-2002)
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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER
I. Marital History of Sampled Number Holder
Number Holder Agrees With Marital History in DR Summary
Number Holder 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:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER
J. Computation Information
1. Work Issues

Explanation

Wages
Self-Employment
Lag Wages/SEI
Gaps
Incomplete Postings
Duplicate/Erroneous Postings
Annual Reports
None Apply
2. Military Service

NONE

a. Branch of Service:

b. Serial Number:

c. Dates of Active Military Duty After September 7, 1939:
From
From

To
To

ALG/PRVIPRE
ALG/PRVIPRE

d. NH Receives or is 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 7 or more years of railroad work alleged?
YES
4. Prior Period(s) of Disability

NO
NONE

a. Date DIB Application Filed:
b. Latest EOD:

Termination Date:

c. Prior EOD:

Termination Date:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER

Consolidated Review

J. Computation Information

J. Computation info.

1. Work Issues

1. Work Issues

Number Holder Agrees With DR Summary

Number Holder Disagrees With DR Summary:
(Complete Below and Obtain an SSA-795)
Year

Amount on E/R

Amount Alleged

2. Military Service

2. Military Service

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

3. Railroad Employment

3. RR Employment

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)
4. Prior Period(s) of Disability

4. Prior Period(s) of Disability

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER
J. Computation Information
5. Windfall Elimination Provision
COMPLETE FOR LIVING NUMBER HOLDER BORN JANUARY 2, 1924 OR LATER
a. NH has 30 or More Special Minimum Coverage Years.
YES (Go to II.K.)

NO

b. NH Is Entitled to a Pension or Lump Sum in Lieu of a Monthly Periodic Pension Based on Work After
1956 Not Covered by Social Security. Note: A Lump Sum as Described Above Qualifies as a Pension
Under This Provision.
YES

NO

(1) Date of First Eligibility to Pension:
Month

Year

(If Prior to 1986, Go to II.K.)

(2) Date of First Entitlement to Pension:
Month

Year

(If Prior to 1986, Go to II.K)

(3) Agency or Organization from Which the Pension Is Received.
Name:
Address:
(4) Period(s) of Employment Upon Which the Pension Is Based. (Include Both Employment Covered and
Not Covered by Social Security.)
From (Month, Year):

To (Month, Year):

From (Month, Year):

To (Month, Year):

(5) Period(s) of Employment After 1956 Not Covered by Social Security That Is Used to Determine the
Pension.
From (Month, Year):

To (Month, Year):

From (Month, Year):

To (Month, Year):

(6) Proof of the amount of the pension is needed for the first month the claimant is concurrently
entitled to the pension and the Social Security benefit
Monthly Amount: $

Form SSA-2930-BK (07-2000) (EF 2-2002)
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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER
J. Computation Information
5. Windfall Elimination Provision

Consolidated Review
J. Computation info.
5. WEP

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain and Obtain Verification, If Necessary)

Development/Findings/Remarks:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER
K. Nonmedical Disability Information

NOT APPLICABLE

1. Period(s) of Disability
a. Date Disability Application Filed:
b. Current Alleged Onset Date:
c. Current Established Onset Date:
d. Prior Established Onset Date:

Termination Date:

2. Disability Related Work Information
a. Earnings After Current Alleged Onset Date
YES

NO (Go to II.K.3.)

b. SGA Determination in File (SSA-820/SSA-821)
YES

NO

3. Worker's Compensation/Public Disability Benefit (WC/PDB)
a. NH Filed for WC/PDB
YES (Complete Below)

NO

Employer

Insurance Carrier

Name:

Name:

Address:

Address:

b. WC/PDB Affects Review Period Payment

YES (Complete Below)

NO

Describe Evidence in File and Type of Payments Received:

4. Child Care Dropout Years
Child Care Dropout Apply in Computation of Benefits
YES (Complete Below)

NO

Describe Documentation in Claims Folder/MCS Screens:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER

Consolidated Review

K. Nonmedical Disability Information

K. Nonmedical DIB Information

NOT APPLICABLE
1. Period(s) of Disability

1. Period(s) of Disability

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

2. Disability Related Work Information
Date Number Holder Last Worked:

2. Disability Related Work
Information

IF THIS DATE IS LATER THAN CURRENT ALLEGED ONSET
DATE LISTED IN II.K1.b. ON PAGE 12, SECURE AN SSA820/SSA-821 AND VERIFICATION AS APPROPRIATE.
3. Worker's Compensation/Public Disability Benefits (WC/PDB)

3. WC/PDB

Number Holder With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

4. Child Care Dropout Years

4. Child Care Dropout Years

a. Years the NH Lived with His/Her Child or Spouse's Child Under
Age 3 Since 1950:

None or Enter Years:
b. Years in II.K.4.a Above in Which the NH Did Not Work.

Development/Findings/Remarks:

Form SSA-2930-BK (07-2000) (EF 2-2002)
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DESK REVIEW
II. NUMBER HOLDER
L. SMI Determination

NOT APPLICABLE

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

NO (Explain)

M. Misinformation/Contact With SSA Prior to Date Claim Filed
Would it have been to the number holder's advantage to file for benefits at an earlier date?
YES (Explain)

NO

N. Criminal Activities
NH Not Involved in Any Criminal Activities Listed Below
Deportation
Offenses Against the National

Subversive Activities
Imprisonment for a Felony

Security (Hiss Act)
NH Entitled on Basis of His Own Disability and that Disability Appears to Have Occurred or Was
Aggravated by the Commission of a Felony After October 19, 1980, and for which the Person Was
Convicted
Evidence Needing Verification

O. Representative payee
Does the claims folder indicate an unresolved representative payee issue (need for payee change, etc.) for
the sampled number holder?
YES (Explain)

Form SSA-2930-BK (07-2000) (EF 2-2002)
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NO

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FIELD/TELEPHONE REVIEW
II. NUMBER HOLDER

Consolidated Review

L. SMI Determination

L. SMI Determination

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

M. Misinformation/Contact With SSA Prior to Date Claim Filed
If II.M. of the desk review summary is answered YES, did the
number holder inquire about filing at an earlier time?

M. Misinformation/Contact With
SSA Prior to DCF

(Explain)

N. Criminal Activities
If any of the criminal activities listed in II.N. of the desk review
summary are involved, discuss and resolve below.

N. Criminal Activities

O. Representative Payee
There is an indication that an unresolved representative payee
issue exists (need for payee change, etc.) for the sampled number
holder.
YES (Explain)

Form SSA-2930-BK (07-2000) (EF 2-2002)
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O. Representative Payee

NO

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CASE SUMMARY
II. NUMBER HOLDER
P. 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.
Section A

Section B

Section C

Section D

Section E

Section F

Section G

Section H

Section I

Section J

Section K

Section L

Section M

Section N

Section O

Additional Development/Findings/Remarks:

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

Form SSA-2930-BK (07-2000) (EF 2-2002)
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