BASIC (11-81)

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

A. Sample form

G-NL_00701.515A

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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 seven fill-ins:

  1. month and year disability ceased

  2. last month and year benefits due

  3. last month and year of HI/SMI entitlement

  4. month and year premiums paid through

  5. premium amount due

  6. month and year premiums due through

  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 - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013