BASIC (11-81)

NL 00701.450 Form SSA-L1019 (Formerly SSA-L368C) — DIB Cessation (T21) — DIB Underpayment — SMI Premium Arrearage

A. Sample form

G-NL_00701.450A

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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. last month and year benefits were paid.

  5. period benefits due—month(s) and year(s).

  6. month and year premiums paid through.

  7. amount of check.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701450
NL 00701.450 - Form SSA-L1019 (Formerly SSA-L368C) -- DIB Cessation (T21) -- DIB Underpayment -- SMI Premium Arrearage - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013