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