Request for Withdrawal of Application

SOCIAL SECURITY ADMINISTRATION
Refer To:

Office of Disability Adjudication and Review
Address 1
Address 2
City, ST Zip
Date:

Name
Address 1
Address 2
City, ST Zip

Dear Claimant's/Representative's Name:
We received a request to withdraw your application. Please carefully read the attached SSA-521
form. Complete and return it in the enclosed envelope.
If You Have Any Questions
If you have any questions, please contact this office. Our telephone number and address are
shown above.
If you do not return the enclosed form, we will proceed with your hearing.

Sincerely,

**[Name]**
Administrative Law Judge
Cc: **[Representative]**
Enclosures:
SSA-521