BASIC (11-81)

NL 00701.460 Form SSA-L1021 (Formerly SSA-L369) — DIB Cessation (T20 and T28) — No DIB OPA/UPA — No HI/SMI

A. Sample form

G-NL_00701.460A

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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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701460
NL 00701.460 - Form SSA-L1021 (Formerly SSA-L369) -- DIB Cessation (T20 and T28) -- No DIB OPA/UPA -- No HI/SMI - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013