Reverse Side

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.

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 premium due through.

7. (7) 

   claim number and BIC.