BASIC (11-81)

NL 00701.470 Form SSA-L1023 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — SMI Premium Refund

A. Sample form

G-NL_00701.470A

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B. Preparation of form

This form notice and the appropriate fill-ins will be designated on Form SSA-573.

Refer to the latest Form SSA-3925-C1 or Form SSA-833-U5 in file for completing the name, address and claim number.

This notice requires three fill-ins:

  1. month and year disability ceased

  2. last month and year benefits due

  3. last month and year of HI/SMI entitlement


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701470
NL 00701.470 - Form SSA-L1023 -- DIB Cessation (T20 and T28) -- No DIB OPA/UPA -- SMI Premium Refund - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013