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	New	Available
Addendum - 0015 (Final).docx	Supplementary Document	Uploaded 2026-06-26	Available
Supporting Statement-0015 (Final).docx	Supporting Statement A	Uploaded 2026-06-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43688	Request for Withdrawal of Application - SSA-521 submitted before approving benefit application (pre-adjudication).	Form	Modified	Request for Withdrawal of Application
43688	Request for Withdrawal of Application - SSA-521 submitted before approving benefit application (pre-adjudication).	Other-Revised PA Statement	Modified
280824	Request for Withdrawal of Application - SSA-521 submitted after receiving benefits. (post-adjudication)	Form	New	Request for Withdrawal of Application
280824	Request for Withdrawal of Application - SSA-521 submitted after receiving benefits. (post-adjudication)	Other-Revised Privacy Act Statement	New

ICR Details

OMB Control No: 0960-0015	ICR Reference No: 202603-0960-017
Status: Received in OIRA	Previous ICR Reference No: 202105-0960-006
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	Date Submitted to OIRA: 06/26/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2026
Responses	81,891	75,127
Time Burden (Hours)	81,891	6,261
Cost Burden (Dollars)	0	0

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Abstract: Form SSA 521, Request for Withdrawal of Application, allows claimants to specify which application they want to withdraw and the reason for the withdrawal. 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. 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:
	91 FR 22569	04/27/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 38748	06/26/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Request for Withdrawal of Application - SSA-521 submitted after receiving benefits. (post-adjudication)	SSA-521	Request for Withdrawal of Application
Request for Withdrawal of Application - SSA-521 submitted before approving benefit application (pre-adjudication).	SSA-521	Request for Withdrawal of Application

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	81,891	75,127	0	0	6,764	0
Annual Time Burden (Hours)	81,891	6,261	0	0	75,630	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 cleared this ICR in 2023, the burden was 6,261 hours. However, we are currently reporting a burden of 6,824 hours. The increase in burden is due to increase in the number of responses from 75,127 to 81,891. These figures represent current Management Information data. *Note: The total burden reflected in ROCIS is 81,891, while the burden cited in #12 of the Supporting Statement is 6,824. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, travel burden + learning costs. In contrast, the chart in #12 above reflects actual burden.

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Annual Cost to Federal Government: $1,132,811

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: 06/26/2026

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