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 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 INDIVIDUAL

SOCIAL SECURITY NUMBER

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

YOUR SOCIAL SECURITY NUMBER

TYPE OF BENEFIT YOU WANT TO WITHDRAW

IF APPLICABLE, DO YOU WANT TO KEEP

DATE OF APPLICATION

Yes

MEDICARE BENEFITS?

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entitlement has been made, there must be repayment of all benefits paid on the application I want withdrawn, and all other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withdrawn and all related material will remain a part of the records of the Social Security Administration and that this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
HERE

Telephone Number (include area code)

X

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

SIGNATURE OF SSA EMPLOYEE

BENEFITS NOT
REPAID

CONSENT(S) NOT
OBTAINED

TITLE

DATE
CLAIMS
AUTHORIZER

Form SSA-521 (10-2012) EF (10-2012)
Destroy Prior Editions

OTHER (Attach special
determination)

OTHER (Specify)

Additional Remarks:

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act
Statement and PRA

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.
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.
Form SSA-521 (10-2012) EF (10-2012)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
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. We will use the information you provide to cancel your application for benefits.
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 rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us); and,
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled Claims Folders
Systems. Additional information about this and other system of records notices and our
programs are available from our Internet website at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.