HI 01001.381 Exhibit — Teletype Message to RRB Regarding PDA Status
| To: |
Railroad Retirement Board |
| |
Health Benefits |
| |
844 Rush Street |
| |
Chicago, Illinois 60611 |
| From: |
SSA PSC NE MAT SE GL MAM WN DBP DIO |
| RE: |
RR No. (RRB Annuity No.) |
| |
SSA CAN (SSN/BIC) |
| |
Name |
SMI jurisdiction transfer processed (mo/da/yr). The correct premium due amount as
of SOM (mo/yr) was ($$$¢¢) (overage, arrearage). SSA collected premiums through coverage
month (mo/yr).