Form SSA-521 Request for Withdrawal of Application

Page 2 of 2

Form SSA-521 (XX-2018) UF
Additional Remarks:

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy

Sections 202, 205, 223 and 1872 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this
Act Statement
information is voluntary. However, failing to provide all or part of the information may cause continued consideration of your
benefits claim.
We will use the information to consider withdrawal of your application for benefits. We may also share your information for the
following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to
the individual's capability to manage his or her affairs of his or her eligibility for or entitlement to benefits under the
Social Security program when the individual is unable to provide information being sought; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration in the efficient administration of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-00089, entitled Claims
Folders Systems. Additional information and a full listing of all our SORNs are available on our website at
https://www�ssa,gov.lprivacy_.
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.socialse�,9..ov. 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, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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. 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 will use the information you provide to cancel your application for benefits. We may also
share your information for the following purposes, called routine uses:
•

To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for Social Security Administration
(SSA) as authorized by law, and they need access to personally identifiable information
in SSA records in order to perform their assigned agency functions; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs.

In addition, we may share the information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy.