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NL: Notices, Letters and Paragraphs

Effective Dates: 06/18/2013 - Present

BASIC (11-81)

A. Sample form

G-NL_00701.445A

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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.

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