Form SSA-521 Request for Withdrawal of Application

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0015

TOE 420

REQUEST FOR WITHDRAWAL OF APPLICATION

Do not write in this space

IMPORTANT NOTICE ⎯ This is a request to cancel your application. If it is approved, the
decision we made on your application will have no legal effect, all rights attached to an
application, including the rights of reconsideration, hearing, and appeal will be forfeited, and
any payments we made to you or anyone else on the basis of that application will have to be
returned. You must then reapply if you want a determination of your Social Security rights at
any time in the future but any subsequent application may not involve the same retroactive
period. This procedure is intended to be used 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 INDIVIDUAL

SOCIAL SECURITY NUMBER

PRINT YOUR NAME (First name, middle initial, last name)

DATE OF APPLICATION

TYPE OF BENEFIT

TYPE OF APPLICATION

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want withdrawn, and all other persons whose benefits would be affected must consent to this withdrawal.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further understand that the application withdrawn and all related material will remain a part of the records of the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
HERE

Telephone Number (include area code)

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
BECAUSE

BENEFITS NOT
REPAID

SIGNATURE OF SSA EMPLOYEE

CONSENT(S) NOT
OBTAINED

TITLE
CLAIMS
AUTHORIZER

Form SSA-521 (07-2003) EF (02-2005) Destroy Prior Editions

OTHER (Attach special
determination)
OTHER (Specify)

DATE

Additional Remarks:

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of
other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for
benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or give out are available in Social Security Offices. If
you want to learn more about this, contact any Social Security Office.
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 THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex
Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

See Revised Paperwork
Reduction Act Statement

SSA-521 (07-2003) EF (02-2005) Destroy Prior Editions

Privacy Act Statement
Collection and Use of Personal Information
Sections 202 (a), 205 (a), and 1872 of the Social Security Act, as amended, authorize us
to collect this information. The information you provide will be used to cancel your
application for benefits.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may cause continued consideration of your benefits claim.
We rarely use the information you supply for any purpose other than for cancelling an
application. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another
agency in accordance with approved routine uses, which include but are not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state, or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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. The office is 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, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.