BASIC (11-81)

A. Sample form

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B. Preparation of form

This form notice and the appropriate fill-ins will be designated on Form SSA-573.

Refer to the latest Form SSA-3925-C1 or Form SSA-833-U5 in file for completing the name, address and claim number.

This notice requires seven 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