This form notice and the appropriate fill-ins will be designated on Form SSA-573.

Refer to the latest Form SSA-3925-C1 or Form SSA-833-U5 in file for completing the name, address and claim number.

This notice requires seven fill-ins:

1. 1. 

   month and year disability ceased

2. 2. 

   last month and year benefits due

3. 3. 

   last month and year of HI/SMI entitlement

4. 4. 

   month and year premiums paid through

5. 5. 

   premium amount due

6. 6. 

   month and year premiums due through

7. 7. 

   claim number and BIC