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.
month and year disability ceased.
last month and year benefits due.
last month and year of HI/SMI entitlement.
month and year premiums paid through.
month and year premium due through.