Basic (11-81)

NL 00701.440 Form SSA-L1017 (Formerly SSA-L368A) — DIB Cessation (T21) — No DIB OPA/UPA HI/SMI Arrearage

A. Sample form

Reverse Side

B. Preparation of form

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:

  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) 

    month and year premiums paid through.

  5. (5) 

    premium amount due.

  6. (6) 

    month and year premium due through.

  7. (7) 

    claim number and BIC.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701440
NL 00701.440 - Form SSA-L1017 (Formerly SSA-L368A) — DIB Cessation (T21) — No DIB OPA/UPA HI/SMI Arrearage - 03/18/1995
Batch run: 03/07/2014
Rev:03/18/1995