TN 89 (11-23)

SI 00820.132 Periodic Reporting Income Summary Worksheets

A. Introduction

The “Periodic Reporting Income Summary” worksheets (SSA-5125) in SI 00820.132D may be reproduced and completed by the certifier to summarize and certify verified wage data from pay stubs in periodic reporting situations, in lieu of photocopying the pay stubs for the file. They also may be used to summarize unearned income data which is reported periodically. A separate summary worksheet should be completed for each type of income. The worksheets below differ from the income summary sheets in SI 00820.131. They provide for certification following each month rather than only at the end of the page to permit the same form to be used repeatedly and certified each month by the individual entering that month's data.

Use of these worksheets is optional. FO's may use either the income summary worksheets in SI 00820.131D or the periodic reporting income summary worksheets in SI 00820.132D in periodic reporting situations.

Electronic versions of the SSA-5125 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 deductions 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 income if one (or possibly more) pay slips or other documents for a particular month are missing.

  9. i. 

    Sign and date the worksheet next to each month completed.

2. Documentation

Document the periodic reporting 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 00820.141, Retention procedures for periodic wage reporting,

SI 00830.420 and SI 01320.145, Child support and deeming.

D. Exhibits – SSA-5125 - Periodic Reporting Income Summary 2012 - 2014)

Jan. 2012- Dec. 2012

Jan. 2013- Dec. 2013

Jan. 2014 - Dec. 2014

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

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

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

To Link to this section - Use this URL:
SI 00820.132 - Periodic Reporting Income Summary Worksheets - 11/20/2023
Batch run: 11/20/2023