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:
month and year disability ceased
last month and year benefits due
“YOUR FAMILY” or “YOUR SPOUSE” or “YOUR CHILDREN” or “YOUR CHILD” (as applicable)
last month and year of HI/SMI entitlement
last month and year benefits were paid
month(s) and year(s) benefits due
month and year premium paid through