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 for completing the name, address and claim number.

This notice requires eight fill-ins:

1. month and year disability ceased

2. last month and year benefits due

3. “YOUR FAMILY” or “YOUR SPOUSE” or “YOUR CHILDREN” or “YOUR CHILD” (as applicable)

4. last month and year of HI/SMI entitlement

5. last month and year benefits were paid

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

7. month and year premiums paid through

8. amount of check