If the disability examiner or claims authorizer requests this notice, use Form SSA-L250. The source of information for completing the fill-ins for this notice is Form SSA-559, Transmittal Slip for Claims Folder.

Fill-ins:

1. (1) 

   “Type of Benefit” shown on Form SSA-559.

2. (2) 

   month and year.

NOTE: Paragraph 258 will be automatically included on Form SSA-L250 by the typist unless dictated information or paragraph 257 is indicated on Form SSA-559.