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) 

   last month and year benefits were paid.

5. (5) 

   period benefits due—month(s) and year(s).

6. (6) 

   month and year premiums paid through.

7. (7) 

   amount of check.