Reverse Side

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 or completing the name, address and claim number.

This notice requires seven 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

4. 4. 

   last month and year benefits were paid

5. 5. 

   month(s) and year(s) benefits due

6. 6. 

   month and year premium paid through

7. 7. 

   amount of check