BASIC (11-81)

NL 00701.490 Form SSA-L1027 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — HI/SMI Premium Arrearage — Auxiliaries in NH's Household

A. Sample form

G-NL_00701.490A-1

Printer Friendly Version

Reverse Side

G-NL_00701.490A-2

Printer Friendly Version

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 eight 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)

  4. last month and year of HI/SMI entitlement

  5. month and year premiums paid through

  6. premium amount due

  7. month and year premiums due through

  8. claim number and BIC


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701490
NL 00701.490 - Form SSA-L1027 -- DIB Cessation (T20 and T28) -- No DIB OPA/UPA -- HI/SMI Premium Arrearage -- Auxiliaries in NH's Household - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013