Basic (11-81)

NL 00701.505 Form SSA-L1030 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — HI/SMI With No Overage or Arrearage — Auxiliaries in NH's Household

A. Sample form

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 four fill-ins:

  1. 1. 

    month and year disability ceased

  2. 2. 

    last month and year benefits due

  3. 3. 

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

  4. 4. 

    last month and year of HI/SMI entitlement


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701505
NL 00701.505 - Form SSA-L1030 — DIB Cessation (T20 and T28) — No DIB OPA/UPA — HI/SMI With No Overage or Arrearage — Auxiliaries in NH's Household - 03/18/1995
Batch run: 03/07/2014
Rev:03/18/1995