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:
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1.
month and year disability ceased
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2.
last month and year benefits due
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3.
“YOUR FAMILY” or “YOUR SPOUSE” or “YOUR CHILDREN” or “YOUR CHILD” (as applicable)