OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Request for Withdrawal of Application - SSA-521 submitted before approving benefit application (pre-adjudication).

IC 43688 under ICR 202603-0960-017 · OMB 0960-0015.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form SSA-521
Request for Withdrawal of Application Request for Withdrawal of Application - SSA-521 submitted before approving benefit application (pre-adjudication).		 Form
Revised Privacy Act Statement-SSA-521.docx Other-Revised PA Statement
SSA-521 Request for Withdrawal of Application
ssa-521 -Revised.pdf 		Form
ssa-521 - current.pdf
SSA-521 - Current		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-521 Yes Yes Fillable Printable
Other-Revised PA Statement No   Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 19,995 0 0 -55,132 0 75,127
Annual IC Time Burden (Hours) 19,995 0 0 13,734 0 6,261
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
SSA-521 - Current 04/16/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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