BASIC (11-81)

NL 00701.480 Form SSA-L1025 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — HI/SMI With No Premium Overage or Arrearage

A. Sample form

G-NL_00701.480A

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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/0900701480
NL 00701.480 - Form SSA-L1025 -- DIB Cessation (T20 and T28) -- No DIB OPA/UPA -- HI/SMI With No Premium Overage or Arrearage - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013