BASIC (11-81)

NL 00701.475 Form SSA-L1024 — DIB Cessation (T20 and T28) — DIB Underpayment — SMI Premium Arrearage

A. Sample form

G-NL_00701.475A-1

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Reverse Side

G-NL_00701.475A-2

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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 or completing the name, address and claim number.

This notice requires seven 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. month(s) and year(s) benefits due

  6. month and year premium paid through

  7. amount of check


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701475
NL 00701.475 - Form SSA-L1024 -- DIB Cessation (T20 and T28) -- DIB Underpayment -- SMI Premium Arrearage - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013