BASIC (11-81)

A. Sample form

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Reverse Side

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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. month and year disability ceased.

2. last month and year benefits due.

3. last month and year of HI/SMI entitlement.

4. month and year premiums paid through.

5. premium amount due.

6. month and year premium due through.

7. claim number and BIC.