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    Request For Withdrawal of Application

    Uploaded by

    Egziabher Bin JoAnn
    This document is a request form for withdrawing a prior application submitted to the Social Security Administration. It explains that withdrawing an application means the initial decision is void and rights to appeal are forfeited. It also notes the applicant must return any benefits paid and reapply in the future. The form requests information like name, reason for withdrawing, and signature of the applicant. It informs that some reasons like intending to continue working require advising on alternatives to withdrawal.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Request For Withdrawal of Application

    Uploaded by

    Egziabher Bin JoAnn
    164 views2 pages
    This document is a request form for withdrawing a prior application submitted to the Social Security Administration. It explains that withdrawing an application means the initial decision is void and rights to appeal are forfeited. It also notes the applicant must return any benefits paid and reapply in the future. The form requests information like name, reason for withdrawing, and signature of the applicant. It informs that some reasons like intending to continue working require advising on alternatives to withdrawal.

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    Form: ssa-521

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    This document is a request form for withdrawing a prior application submitted to the Social Security Administration. It explains that withdrawing an application means the initial decision is void and rights to appeal are forfeited. It also notes the applicant must return any benefits paid and reapply in the future. The form requests information like name, reason for withdrawing, and signature of the applicant. It informs that some reasons like intending to continue working require advising on alternatives to withdrawal.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    164 views2 pages

    Request For Withdrawal of Application

    Uploaded by

    Egziabher Bin JoAnn
    This document is a request form for withdrawing a prior application submitted to the Social Security Administration. It explains that withdrawing an application means the initial decision is void and rights to appeal are forfeited. It also notes the applicant must return any benefits paid and reapply in the future. The form requests information like name, reason for withdrawing, and signature of the applicant. It informs that some reasons like intending to continue working require advising on alternatives to withdrawal.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Form SSA-521 (11-2018) UF

    Discontinue Prior Editions Page 1 of 2


    Social Security Administration TOE 420 OMB No. 0960-0015
    REQUEST FOR WITHDRAWAL OF APPLICATION Do not write in this space

    IMPORTANT NOTICE - This is a request to withdraw your application. If we approve it, the
    decision we made on your application will have no legal effect. You will forfeit all rights attached
    to an application, including the rights of appeal. You will have to return any payment we made to
    you or anyone else on the basis of that application. You must then reapply if you want a
    determination of your Social Security rights at any time in the future. Any subsequent application
    may not involve the same retroactive period. We intend for you to use this procedure only when
    your decision to file has resulted, or will result, in a disadvantage to you. Your local Social
    Security office will be glad to explain whether, and how, this procedure will help you.
    NAME OF WAGE EARNER, SELF-EMPLOYED INDIVIDUAL, OR ELIGIBLE SOCIAL SECURITY NUMBER
    INDIVIDUAL
    IF DIFFERENT, PRINT YOUR NAME (First name, middle initial, last name) YOUR SOCIAL SECURITY NUMBER

    TYPE OF BENEFIT YOU WANT TO WITHDRAW DATE OF APPLICATION IF APPLICABLE, DO YOU WANT TO KEEP
    MEDICARE BENEFITS? Yes No

    I hereby request the withdrawal of my application, dated as above, for the reasons stated below. I understand that (1) this request
    may not be cancelled after 60 days from the mailing of notice of approval; and (2) if a determination of my entitlement has been
    made, there must be repayment of all benefits paid on the application I want withdrawn, and all other persons whose benefits
    would be affected must consent to this withdrawal. I further understand that the application withdrawn and all related material will
    remain a part of the records of the Social Security Administration and that this withdrawal will not affect the proper crediting of
    wages or self-employment income to my Social Security earnings record.
    Give reason for withdrawal. (If you need more space, use the reverse of this form.)
    1. I intend to continue working. (I have been advised of the alternatives to withdrawal for applicants under full retirement
    age and still wish to withdraw my application.)

    2. Other (Please explain fully):

    Continued on reverse
    SIGNATURE OF PERSON MAKING REQUEST
    Signature (First name, middle initial, last name) (Write in ink) Date (Month, day, year)
    SIGN
    Telephone Number (include area code)
    HERE
    Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)

    City and State ZIP Code Enter Name of County (if any) in which you now live

    Witnesses are required ONLY if this request has been signed by mark (X) above. If signed by mark (X), two witnesses to
    the signing who know the person making the request must sign below, giving their full addresses.
    1. Signature of Witness 2. Signature of Witness

    Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code)

    FOR USE OF SOCIAL SECURITY ADMINISTRATION

    APPROVED NOT APPROVED BENEFITS NOT CONSENT(S) NOT OTHER


    BECAUSE REPAID OBTAINED (Attach special determination)

    SIGNATURE OF SSA EMPLOYEE TITLE OTHER (Specify) DATE


    CLAIMS
    AUTHORIZER
    Form SSA-521 (11-2018) UF Page 2 of 2
    Additional Remarks:

    Privacy Act Statement


    Collection and Use of Personal Information
    Sections 202, 205, 223 and 1872 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
    information is voluntary. However, failing to provide us with all or part of the information may cause continued consideration of
    your benefits claim.

    We will use the information you provide to cancel your application for benefits. We may also share your information for the
    following purposes, called routine uses:

    • To student volunteers and other workers, who technically do not have the status of Federal employees, when they are
    performing work for Social Security Administration (SSA) as authorized by law, and they need access to personally
    identifiable information in SSA records in order to perform their assigned agency functions; and

    • To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
    of its programs.

    In addition, we may share the information in accordance with the Privacy Act and other Federal laws. For example, where
    authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
    other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
    debts under these programs.

    A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims Folders
    Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional information and a full listing of all
    our SORNs are available on our website at www.ssa.gov/privacy.
    Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
    Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
    Management and Budget control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts,
    and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You
    can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are listed under U.S.
    Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213
    (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401Security Blvd., Baltimore, MD
    21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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