Request for Withdrawal of Application

ICR 201802-0960-001

OMB: 0960-0015

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2018-06-19
Supporting Statement A
2018-06-25
IC Document Collections
IC ID
Document
Title
Status
43688 Modified
ICR Details
0960-0015 201802-0960-001
Active 201708-0960-004
SSA
Request for Withdrawal of Application
Revision of a currently approved collection   No
Regular
Approved with change 10/18/2018
Retrieve Notice of Action (NOA) 06/25/2018
In accordance with 5 CFR 1320, the information collection is approved for three years.
  Inventory as of this Action Requested Previously Approved
10/31/2021 36 Months From Approved 10/31/2018
31,827 0 39,000
2,652 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.

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

Not associated with rulemaking

  83 FR 12455 03/21/2018
83 FR 26736 06/08/2018
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 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
No
Yes
Miscellaneous Actions
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.

$274,934
No
    Yes
    Yes
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.
06/25/2018


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