NL 00701.540 Form SSA-L1037 — Disability Cessation (T22) — No DIB OPA/UPA — HI/SMI Premium Arrearage — Auxiliaries in NH's Household
A. Sample form
Printer Friendly Version
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 eight fill-ins:
month and year disability ceased
last month and year benefits due
“YOUR FAMILY” or “YOUR SPOUSE” or “YOUR CHILDREN” or YOUR CHILD” (as applicable)
last month and year of HI/SMI entitlement
month and year premiums paid through
premium amount due
month and year premiums due through
claim number and BIC