NL 00701.450 Form SSA-L1019 (Formerly SSA-L368C) — DIB Cessation (T21) — DIB Underpayment — SMI Premium Arrearage
A. Sample form
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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.
month and year disability ceased.
last month and year benefits due.
last month and year of HI/SMI entitlement.
last month and year benefits were paid.
period benefits due—month(s) and year(s).
month and year premiums paid through.
amount of check.