Request for Withdrawal of Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-521 Request for Withdrawal of Application	Form	Modified	Available
Form SSA-521 Request for Withdrawal of Application	Form	Modified	Repair queued
Addendum - 0015 (Final).docx	Supplementary Document	Uploaded 2021-09-07	Available
Addendum - 0015 (Final).docx	Supplementary Document	Uploaded 2021-09-07	Repair queued
Supporting Statement - 0015 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-06-13	Available
Supporting Statement - 0015 (Final).docx	Supporting Statement A	Uploaded 2021-09-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43688	Request for Withdrawal of Application	Form	Modified	Request for Withdrawal of Application
43688	Request for Withdrawal of Application	Form	Modified
43688	Request for Withdrawal of Application	Other-Revised PA and PRA Statements	Modified

ICR Details

OMB Control No: 0960-0015	ICR Reference No: 202105-0960-006
Status: Active	Previous ICR Reference No: 201802-0960-001
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: 06/22/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/09/2021
Terms of Clearance: The agency made minor changes to the supporting statement to provide additional detail.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved	06/30/2023
Responses	75,127	0	31,827
Time Burden (Hours)	6,261	0	2,652
Cost Burden (Dollars)	0	0	0

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Abstract: SSA employees collect Form SSA-521, which documents the information SSA needs to process the withdrawal of an application for benefits. Form SSA-521 is our preferred instrument for a withdrawal request; however, any written request for withdrawal signed by the claimant or a proper applicant on the claimant’s behalf will suffice. Each time an individual wishes to withdraw an application for benefits, he or she completes and signs Form SSA-521. Typically, respondents complete the form themselves and will not need information from someone else to complete the form. SSA uses the information from the SSA-521 to process the request for withdrawal. The respondents are beneficiaries or 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:
	86 FR 35371	07/02/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 49403	09/02/2021
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

table that charts list 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	75,127	31,827	0	0	43,300	0
Annual Time Burden (Hours)	6,261	2,652	0	0	3,609	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: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2018, the burden was 2,652 hours. However, we are currently reporting a burden of 6,261 hours. This change stems from an increase in the number of responses from 31,827 to 75,127. 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. The current figures represent the latest Management Information data.

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Annual Cost to Federal Government: $649,097

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? No

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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: 09/09/2021

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