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SI 00820.131: Income Summary Worksheets

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  • Effective Dates: 10/15/2014 - Present
  • Effective Dates: 01/16/2018 - Present
  • TN 48 (11-08)
  • SI 00820.131 Income Summary Worksheets
  • A. Introduction
  • The “Income Summary” worksheets (SSA-5124) in SI 00820.131D may be reproduced and completed by the certifier to summarize and certify verified earned and unearned income data from pay stubs or other documents, in lieu of photocopying the documents for the file. A separate summary worksheet should be completed for each type of income. Use of these worksheets is optional.
  • Electronic versions of the SSA-5124 can be downloaded from http://chinet.ch.ssa.gov/area4web/forms.html .
  • B. Procedure
  • 1. Completion of Worksheets
  • * Complete the identifying information at the top of the worksheet.
  • * Circle the dates the income was received.
  • * Enter the weekly, biweekly, or semi-monthly wage amounts in the Gross Wages column.
  • * Enter the weekly, biweekly, or semi-monthly amounts of cafeteria plan deductions in the Cafeteria Plan Deduction column.
  • * Enter the weekly, biweekly, or semi-monthly child support garnishments (for the deemor wage-earner) in the Child Support column.
  • * Use the Other column to document any other deduction from gross wages (e.g., IRWE or BWE). Rename the Other column to reflect the type of deduction.
  • * Compute the monthly totals for each column and enter them on the monthly totals line.
  • * Enter the year-to-date (YTD) total, if desired.
  • NOTE: The YTD total may be useful in determining monthly amounts if one (or possibly more) pay slips or other documents for a particular month are missing.
  • i. Sign and date the worksheet.
  • 2. Documentation
  • Document the income summary worksheet (either reproduced from POMS or locally reproduced on personal computers), in lieu of copies of the documents containing the income data by:
  • * faxing a copy of the income summary worksheet certified by an SSA employee into the Non-Disability Repository (NDRED), or the Certified Electronic Folder (CEF), as appropriate.
  • Once the documentation is stored and viewed for content in either eView or through the NDRED by using CFRMS, there is no need to retain the documentation.
  • Once the documentation is stored and viewed for content in either eView or through the NDRED by using the Claims File User Interface (CFUI), there is no need to retain the documentation.
  • Refer to SI 00820.141C. for documentation procedures on alternative wage reports/periodic wage reports.
  • C. References
  • GN 00301.090, Personnel authorized to certify documents
  • GN 00301.285, Statements and Other Documentation
  • GN 00301.286, Evidence Documentation and Retention
  • GN 00301.288, What Information is Needed on EVID and DROC in PE Situations to Identify the Type of Evidence Submitted
  • SI 00820.102, Cafeteria plans
  • SI 00830.420 and SI 01320.145, Child support and deeming
  • D. Exhibits-SSA-5124 - Income Summary
  • Jan. 2012- Dec. 2012
  • Jan. 2013- Dec. 2013
  • Jan. 2014- Dec. 2014
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  • 1. Income Summary (Jan. 2012 - Dec. 2012)
  •  View PDF Version
  •  View PDF Version
  •  View PDF Version
  • 2. Income Summary (Jan. 2013 - Dec. 2013)
  •  View PDF Version
  •  View PDF Version
  •  View PDF Version
  • 3. Income Summary (Jan. 2014 - Dec. 2014)
  •  View PDF Version
  •  View PDF Version
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