BASIC (11-81)

NL 00701.485 Form SSA-L1026 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — No HI/SMI Auxiliaries in NH's Household

A. Sample form

G-NL_00701.485A

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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. “YOUR FAMILY” or “YOUR SPOUSE” or “YOUR CHILDREN” or “YOUR CHILD” (as applicable)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701485
NL 00701.485 - Form SSA-L1026 -- DIB Cessation (T20 and T28) -- No DIB OPA/UPA -- No HI/SMI Auxiliaries in NH's Household - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013