BASIC (11-81)

A. Sample form

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Reverse Side

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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 or 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. last month and year benefits were paid

5. month(s) and year(s) benefits due

6. month and year premium paid through

7. amount of check