NL 00701.470 Form SSA-L1023 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — SMI Premium Refund
A. Sample form
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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:
month and year disability ceased
last month and year benefits due
last month and year of HI/SMI entitlement