Basic (11-81)

NL 00701.530 Form SSA-L1035 — Disability Cessation (T22) — No DIB OPA/UPA — HI/SMI With No Premium Arrearage or Overage

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 three 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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701530
NL 00701.530 - Form SSA-L1035 — Disability Cessation (T22) — No DIB OPA/UPA — HI/SMI With No Premium Arrearage or Overage - 03/18/1995
Batch run: 03/07/2014
Rev:03/18/1995