Basic (11-81)

NL 00701.515 Form SSA-L1032 — Disability Cessation (T22) — No DIB OPA/UPA — HI/SMI Premium Arrearage

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 seven fill-ins:

  1. 1. 

    month and year disability ceased

  2. 2. 

    last month and year benefits due

  3. 3. 

    last month and year of HI/SMI entitlement

  4. 4. 

    month and year premiums paid through

  5. 5. 

    premium amount due

  6. 6. 

    month and year premiums due through

  7. 7. 

    claim number and BIC


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701515
NL 00701.515 - Form SSA-L1032 — Disability Cessation (T22) — No DIB OPA/UPA — HI/SMI Premium Arrearage - 03/18/1995
Batch run: 03/07/2014
Rev:03/18/1995