Effective Dates: 03/18/1995 - Present Previous | Next

Basic (11-81)

NL 00701.460 Form SSA-L1021 (Formerly SSA-L369) — DIB Cessation (T20 and T28) — No DIB OPA/UPA — No HI/SMI

A. Sample form

B. Preparation of form

Refer to the latest Form SSA-3926-C2 or Form SSA-833-U5 in file for completing the name, address and claim number.

The benefit authorizer will provide all the necessary fill-ins on Form SSA-573.

Fill-ins:

  1. 1. 

    month and year disability ceased.

  2. 2. 

    last month and year benefits due.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701460
NL 00701.460 - Form SSA-L1021 (Formerly SSA-L369) — DIB Cessation (T20 and T28) — No DIB OPA/UPA — No HI/SMI - 03/18/1995
Batch run: 03/07/2014
Rev:03/18/1995