Refer to the latest Form SSA-3926-C2 or Form SSA-833-U5 in file for completing the
name, address and claim number.
The benefit authorizer will provide all the necessary fill-ins on Form SSA-573.
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)
last month and year of HI/SMI entitlement.
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(4)
month and year premiums paid through.
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(6)
month and year premium due through.
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