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:
month and year disability ceased
last month and year benefits due
last month and year of HI/SMI entitlement
month and year premiums paid through
month and year premiums due through