Form SSA-2930 RSI/DI Quality Review Case Analysis - Sampled Number Hol

Form SSA-2930-BK (08-2022)
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Social Security Administration

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OMB No. 0960-0189

RSI/DI QUALITY REVIEW CASE ANALYSIS - SAMPLED NUMBER HOLDER
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 program 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.
1. IDENTIFYING AND REVIEW INFORMATION
A. Study ID Code (SIC):

B. NH's SSN:

C. Sample Selection Date (as shown in Sample Cycle field):
D. Review Amount (as shown in Dollar tab): $
E. Review Amount Determined by OQR (as shown in PHUS): $
F. Explanation of review amount change (if OQR determination is different):
G: NH's Name (As Shown on MBR):
H. NH's Address/Phone
Address:
Phone (Include Area Code):
I. Payee Name Address/Phone
Name:
Address:
Phone (Include Area Code):
NH Under FRA and Entitled to RIB in Closed Year (Complete SSA-4281/SSA-4659)

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
A. Identity

Telephone

Other

B. Other Names and SSNs Shown in Claims Folder/Numident

N/A

1. Other Names:
2. Other SSNs:
C. Date of Birth/U.S. Citizenship/Alien Status
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

5. Evidence/Documentation in Claims Folder/MCS Screens:
6. Evidence Needing Verification:
7. Date of Birth Established by Desk Review:
8. U.S. Citizenship/Alien Status Established by Desk Review:
Remarks:

Lawfully-Present Alien

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
A. Identity
1. Existence Verified by:
Telephone:

Consolidated Review
A. Identity

2. SSN Verified by:
Other:

B. Other Names and SSN's Used
N/A

B. Other Names/SSN's

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

C. Date of Birth and U.S. Citizenship/Alien Status
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

C. DOB and U.S. Citizenship/Alien Status

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
D. Application
1. Benefit Type

RIB

DIB

If DIB, Established Onset Date:

2. Date Claim Filed:
3. MOE (and MOEL Option Code if RIB):
4. MOE Determined by Desk Review:
Remarks:
E. Multiple Entitlement Involved

YES (Complete Below)

NO

1. Claim Number on Non-sampled SSN:
2. Scope of Review on Non-sampled SSN:
Full Review

Limited Review

Not in Scope of Review

F. Other Claims Activity
1. Did the NH ever file for any other benefits (including SSI)?
YES (Explain)

NO

2. Does the NH have any eligible children who have not filed for benefits?
YES (Explain)

3. Unadjudicated Claims Issues:

NO

NONE APPLY

Unprocessed Application

Deemed Filing

Protective Filing

Open Application

Partial Adjudication

Potential Entitlement (Leads)

Delayed Claim

Misinformation

Remarks:

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
D. Application

Consolidated Review
D. Application

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

E. Multiple Entitlement

E. Multiple Entitlement

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

F. Other Claims Activity
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

F. Other Claims Activity

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
G: Underpayment on Sampled SSN Needed to Be Addressed
YES (Explain)

NO

N/A

H. Recovery of Overpayment in Sample Month
YES (Explain)

I. SMI Determination

NO

N/A

N/A

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

NO (Explain)

J. Payment Amount
1. Amount of CMA/SM Check: $

, Sampled Month:

2. Payment Cycle Indicator (CYI):
3. Payment Combined with Other Benefit:
YES

NO

4. Check Amount Affected by Other Withholding/Deductions (e.g., Medicare Premiums, Voluntary Tax Withholding, Alien Tax,
Garnishment, Treasury Offset Program, etc.)
YES (Explain)
Remarks:

NO

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
G. Underpayment
N/A

Consolidated Review
G. Underpayment

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

H. Recovery of Overpayment in Sample Month
N/A

H. Recovery of Overpayment in Sample Month

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

I. SMI Determination
N/A

I. SMI Determination

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

J. Payment Amount
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

J. Payment Amount

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER

NH NEVER MARRIED

K. Marital History of Sampled NH
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:
h. Place Terminated:
i. Evidence/Documentation in Claims Folder/MCS Screens:
j. Evidence Needing Verification:

g. Date Terminated:

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
K. Marital History of Sampled NH
NH Agrees With Marital History in DR Summary
NH Disagrees With Marital History in 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:
h. Place Terminated:
i. Evidence Obtained:
Consolidated Review:

g. Date Terminated:

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
L. Computation Information
1. Work Issues

Explanation

Wages
Self-Employment
Lag Wages/SEI
Gaps
Annual Reports
Duplicates/
Incompletes
Other
NONE

2. Military Service
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?
YES
4. Prior Period of Disability (PPD):
a. PPD Shown on MBR:

NO
NONE
Date of Onset:

Term Date:

Date of Onset:

Term Date:

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

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
L. Computation Information
1. Work Issues

Consolidated Review
L. Computation Information
1. Work Issues

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

2. Military Service

2. Military Service

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

3. Railroad Employment

3. Railroad Employment

NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

4. Prior Period of Disability
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

4. Prior Period of Disability

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
L. Computation Information
5. Windfall Elimination Provision - COMPLETE IF NH BORN JANUARY 2, 1924 OR LATER
a. NH has 30 or More Years of Coverage (YOCs).
YES

NO

b. NH is Entitled to a Foreign or Domestic Pension, or Lump Sum in Lieu of a Monthly Periodic Pension, Based on Work
After 1956 Not Covered by Social Security
YES

NO

(1) Date of First Eligibility to Pension (MM/YYYY):
(2) Date of First Entitlement to Pension (MM/YYYY):
(If either date is prior to 1986, go to 5.d.)
(3) If NH does not have 30 YOCs, does other WEP Exception Apply:
YES Go to 5.d.

NO

c. Information About the Pension
(1) Agency or Organization from Which the Pension Is Received:
Name:
Address:

(2) Total Period(s) of Employment Used to Determine Pension (Both Covered and non-Covered Employment):
From (MM/YYYY):

To (MM/YYYY):

From (MM/YYYY):

To (MM/YYYY):

(3) Period(s) of Employment After 1956 Not Covered by Social Security That Is Used to Determine the Pension:
From (MM/YYYY):

To (MM/YYYY):

From (MM/YYYY):

To (MM/YYYY):

(4) Amount of the Pension in First Month Concurrent Entitlement to Pension and Social Security Benefit:
Monthly Amount: $
d. Evidence/Documentation in Claims Folder/MCS Screens:
e. Evidence Needing Verification:

(Obtain proof if guarantee applies.)

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
L. Computation Information
5. Windfall Elimination Provision
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

Consolidated Review
L. Computation Information
5. WEP

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
M. Current DIB Entitlement

N/A

1. Period(s) of Disability
a. Current Established Onset Date:
c. Prior Period of DIB
YES (Complete below)
Effect on Current Entitlement:
Waiting Period

b. MOE:
NO
Comps

Medicare

2. Disability-Related Work Information
a. Earnings After Current Established Onset Date:
YES (Complete below)

NO

b. Disability-Related Work Issues
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:

Explanation

Other

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
M. Current DIB Entitlement
N/A

Consolidated Review
M. Current DIB Entitlement
1. Period(s) of Disability

1. Period(s) of Disability
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

2. Disability-Related Work Information
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

2. Disability-Related Work Information

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
M. 3. Worker's Compensation/Public Disability Benefit (WC/PCB)
a. NH Filed for WC/PDB:
YES

NO

b. Status of Claim:
Awarded (Complete Below)

Denied

Pending

c. Employer Name and Address
Payer Name and Address
d. Describe Type of Payments Received:
e. WC/PDB Affects Review Period Payment:
YES
NO
(Explain)
f. Documentation in Claims Folder/MCS Screens:
g. Evidence Needing Verification:
4. Child-Care Dropout (Less than 3 Regular Drop-Out Yrs):
YES

NO

a. Child Under Age 3 Lived With NH During a Year That NH Had No Earnings:
YES
NO
b. Documentation in Claims Folder/MCS Screens:
c. Evidence Needing Verification:

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
M. Current DIB Entitlement
3. Worker's Compensation/Public Disability Benefit
(WC/PDB)
NH Agrees with DR Summary

Consolidated Review
M. Current DIB Entitlement
3. WC/PDB

NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

4. Child-Care Dropout Years
NH Agrees with DR Summary
NH Disagrees with DR Summary
Explain:

Evidence Obtained in Field Review:

4. Child-Care Dropout

Form SSA-2930-BK (08-2022)

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DESK REVIEW
2. NUMBER HOLDER
N. Fugitive Felon
a. Are there any unsatisfied felony warrants for NH's arrest or for violations of probation/parole?
YES

NO

b: Evidence/Documentation in Claims Folder/MCS Screens:
c. Evidence Needing Verification:
O. Criminal Activities
NH Not Involved in Any Criminal Activities Listed Below
Removal (formerly Deportation)
Offenses Against the National Security (Hiss Act)
Subversive Activities
Confined for a Criminal Offense
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 the Confinement for a Felony Conviction
Evidence/Documentation in Claims Folder/MCS Screens:
Evidence Needing Verification:
P. Representative Payee
Does the desk review indicate that an unresolved representative payee issue exists (need for payee change, etc.) for the
sampled NH?
YES (Explain)
Remarks:

NO

Form SSA-2930-BK (08-2022)

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TELEPHONE REVIEW
2. NUMBER HOLDER
N. Fugitive Felon
NH states/desk review summary shows that there are no
unsatisfied felony warrants for arrest or for violations of
probation/parole.
YES

Consolidated Review
N. Fugitive Felon

NO (Explain)
Remarks:

Evidence Obtained in Field Review:

O. Criminal Activities
If any of the criminal activities listed in 2.O. of the desk
review summary are involved, discuss and resolve below.

O. Criminal Activities

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

P. Representative Payee

NO
Remarks:

Form SSA-2930-BK (08-2022)

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CASE SUMMARY
2. NUMBER HOLDER
Q. 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

Section P

Additional Development/Findings/Remarks:

SIGNATURE OF REVIEWER(S)
Desk Reviewer

Date:

Field Reviewer

Date:

Consolidated Reviewer

Date:

Form SSA-2930-BK (08-2022)

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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.
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 (OMB) 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.