Request for Withdrawal of Application

Forms and Documents

Document Name	Status
Form SSA-521 Request for Withdrawal of Application Form	Modified
0015 Addendum.doc Supplementary Document	2018-06-19
Supporting Statement - 0015.docx Supporting Statement A	2018-06-25

IC Document Collections

IC ID	Document Title	Status
43688	Request for Withdrawal of Application Form	Modified

ICR Details

OMB Control No: 0960-0015	ICR Reference No: 201802-0960-001
Status: Active	Previous ICR Reference No: 201708-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Withdrawal of Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/18/2018
	Date Received in OIRA: 06/25/2018
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved	10/31/2018
Responses	31,827	0	39,000
Time Burden (Hours)	2,652	0	3,250
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 12455	03/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 26736	06/08/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	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	31,827	39,000	0	-7,173	0	0
Annual Time Burden (Hours)	2,652	3,250	0	-598	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: When we last cleared this IC in 2015, the burden was 3,250 hours. However, we are currently reporting a burden of 2,652 hours. This change stems from a change in the regulations at 20 CFR 404.640, which now limit individuals to one withdrawal approval per lifetime, and they submit the request for withdrawal within 12 months of their current date of entitlement. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

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Annual Cost to Federal Government: $274,934

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/25/2018

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