BASIC (11-81)

A. Sample form

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B. Preparation of form

Refer to Form SSA-3428-U2 (Determination of Disallowance Coding Sheet) “Name and Address Information” filed in block 2 for completing the name and address.

This notice requires two fill-ins:

1. required quarters of coverage

2. number of quarters of coverage the individual has

The necessary fill-ins for this notice should be shown in the “Disallowance Notice Information” filed in block 4. If the fill-ins are not shown, return the claim to the individual who initiated the action.

If additional paragraphs are required, they will be shown on Form SSA-3428-U2 or Form SSA-573.