BASIC (11-81)

NL 00701.555 Form SSA-L1040 — Disability Cessation (T22) — No DIB OPA/UPA — HI/SMI With No Premium Overage or Arrearage — Auxiliaries In NH's Household

A. Sample form

G-NL_00701.555A

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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 four fill-ins:

  1. month and year disability ceased

  2. last month and year benefits due

  3. “YOUR FAMILY” or “YOUR SPOUSE” or “YOUR CHILDREN” or “YOUR CHILD” (as applicable)

  4. last month and year of HI/SMI entitlement


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701555
NL 00701.555 - Form SSA-L1040 -- Disability Cessation (T22) -- No DIB OPA/UPA -- HI/SMI With No Premium Overage or Arrearage -- Auxiliaries In NH's Household - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013