NL 00701.620 Form SSA-L1222 — RIB Disapproval — Lack of Insured Status — Date of Birth Not Established
A. Sample form
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B. Preparation of form
Refer to Form SSA-3428-U2 (Determination of Disallowance Coding Sheet) “Name and Address Information” field in block 2 for completing the name and address.
This notice requires two fill-ins:
required number of quarters of coverage
number of quarters of coverage the individual has
The necessary fill-ins for this notice should be shown in the “Disallowance Notice Information” field in block 4. If the fill-ins are not shown, return the claim to the individual who initiated the action.
If additional paragraphs are required, they will be shown on Form SSA-3428-U2 or Form SSA-573.