TN 89 (11-23)

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 found on the ChiNet Webpage and the InForm Library website.

B. Procedure

1. Completion of Worksheets

  1. a. 

    Complete the identifying information at the top of the worksheet.

  2. b. 

    Circle the dates the income was received.

  3. c. 

    Enter the weekly, biweekly, or semi-monthly wage amounts in the Gross Wages column.

  4. d. 

    Enter the weekly, biweekly, or semi-monthly amounts of cafeteria plan deductions in the Cafeteria Plan Deduction column.

  5. e. 

    Enter the weekly, biweekly, or semi-monthly child support garnishments (for the deemor wage-earner) in the Child Support column.

  6. f. 

    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.

  7. g. 

    Compute the monthly totals for each column and enter them on the monthly totals line.

  8. h. 

    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.

  9. 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:

  • storing a copy of the income summary worksheet certified by an SSA employee in the Non-Disability Repository (NDRED) using the Evidence Portal (EP), or the Certified Electronic Folder (CEF), as appropriate.

Once the documentation is stored and viewed for content in either eView or through NDRED using EP, 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 the Report of Contact page in the Consolidated Claims Experience (CCE) in PE Situations to Identify the Type of Evidence Submitted

MS 09701.001, Evidence Portal (EP) - Overview

SI 00820.102, Cafeteria plans

SI 00830.420 and SI 01320.145, Child support and deeming

D. Exhibits-SSA-5124 - Income Summary

1. Income Summary (Jan. 2012 - Dec. 2012)

2. Income Summary (Jan. 2013 - Dec. 2013)

3. Income Summary (Jan. 2014 - Dec. 2014)

To Link to this section - Use this URL:
SI 00820.131 - Income Summary Worksheets - 11/20/2023
Batch run: 11/20/2023