BASIC (11-81)

NL 00701.440 Form SSA-L1017 (Formerly SSA-L368A) — DIB Cessation (T21) — No DIB OPA/UPA HI/SMI Arrearage

A. Sample form

G-NL_00701.440A-1

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Reverse Side

G-NL_00701.440A-2

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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. month and year disability ceased.

  2. last month and year benefits due.

  3. last month and year of HI/SMI entitlement.

  4. month and year premiums paid through.

  5. premium amount due.

  6. month and year premium due through.

  7. claim number and BIC.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701440
NL 00701.440 - Form SSA-L1017 (Formerly SSA-L368A) -- DIB Cessation (T21) -- No DIB OPA/UPA HI/SMI Arrearage - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013