Request for Withdrawal of Application

OMB 0960-0015

OMB 0960-0015

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.

The latest form for Request for Withdrawal of Application expires 2021-10-31 and can be found here.

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Extension without change of a currently approved collection 1989-12-22
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No material or nonsubstantive change to a currently approved collection 1985-08-29
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No material or nonsubstantive change to a currently approved collection 1981-07-17
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Extension without change of a currently approved collection 1979-08-03
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New collection (Request for a new OMB Control Number) 1974-06-18

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