Request for Withdrawal of Application

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.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-521 Request for Withdrawal of Application Form
Addendum - 0015 (Final).docx Supplementary Document
Supporting Statement - 0015 (Final).docx Supporting Statement A
Request for Withdrawal of Application Form

All Historical Document Collections

202105-0960-006 Approved with change	Revision of a currently approved collection	2021-09-09
201802-0960-001 Approved with change	Revision of a currently approved collection	2018-06-25
201708-0960-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-08-04
201605-0960-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-08-12
201502-0960-009 Approved without change	Revision of a currently approved collection	2015-06-02
201201-0960-010 Approved without change	Revision of a currently approved collection	2012-05-18
200901-0960-001 Approved without change	Revision of a currently approved collection	2009-04-28
200606-0960-011 Approved without change	Extension without change of a currently approved collection	2006-06-14
200308-0960-002 Approved without change	Revision of a currently approved collection	2003-08-22
200009-0960-016 Approved without change	No material or nonsubstantive change to a currently approved collection	2000-09-18
200007-0960-008 Approved without change	Extension without change of a currently approved collection	2000-07-31
199707-0960-004 Approved without change	Extension without change of a currently approved collection	1997-07-17
199403-0960-005 Approved without change	Revision of a currently approved collection	1994-03-31
199102-0960-007 Approved without change	Extension without change of a currently approved collection	1991-02-06
198912-0960-005 Approved without change	Extension without change of a currently approved collection	1989-12-22
198703-0960-001 Approved without change	Revision of a currently approved collection	1987-03-11
198508-0960-012 Approved with change	No material or nonsubstantive change to a currently approved collection	1985-08-29
198405-0960-010 Approved without change	Extension without change of a currently approved collection	1984-05-22
198107-0960-008 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-07-17
197908-0960-004 Approved without change	Extension without change of a currently approved collection	1979-08-03
197406-0960-001 Approved without change	New collection (Request for a new OMB Control Number)	1974-06-18