Request for Withdrawal of Application

ICR 201605-0960-004

OMB: 0960-0015

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Justification for No Material/Nonsubstantive Change
2016-05-31
IC Document Collections
IC ID
Document
Title
Status
43688 Modified
ICR Details
0960-0015 201605-0960-004
Historical Active 201502-0960-009
SSA
Request for Withdrawal of Application
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 08/17/2016
Retrieve Notice of Action (NOA) 08/12/2016
  Inventory as of this Action Requested Previously Approved
08/31/2018 08/31/2018 08/31/2018
39,000 0 39,000
3,250 0 3,250
0 0 0

Form SSA-521 collects the required information to make withdrawal of an application for benefits. A paper SSA-521 is the preferred instrument for executing a withdrawal request. However, any written request for withdrawal signed by the claimant or a proper applicant on the claimant's behalf will suffice. Individuals who wish to withdraw their applications for benefits complete Form SSA-521, or sign the completed form for each request to withdraw. SSA uses the information from Form SSA-521 to process the request for withdrawal. The respondents are applicants for Retirement, Survivors, Disability, and Health Insurance benefits. This is a non-substantive Change Request to include a fillable modality for this ICR.

US Code: 42 USC 405 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  80 FR 9499 02/23/2015
80 FR 30316 05/27/2015
No

1
IC Title Form No. Form Name
Request for Withdrawal of Application SSA-521 Request for Withdrawal of Application

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 39,000 39,000 0 0 0 0
Annual Time Burden (Hours) 3,250 3,250 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$160,000
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/12/2016


© 2024 OMB.report | Privacy Policy