Form SSA-521, Request for Withdrawal Instructions

Provide any additional comments, explanations, or clarifications relevant to your request to withdraw your Social Security application.

Enter the full legal name (first name, middle initial, last name) of the wage earner, self-employed individual, or eligible individual whose application you are withdrawing.

Provide the Social Security number of the wage earner, self-employed individual, or eligible individual whose application you are withdrawing.

Enter your full legal name (first name, middle initial, last name) if it differs from the name provided above.

Provide your Social Security number if it differs from the number provided above.

Sign your full name (first name, middle initial, last name) in ink to confirm your request for withdrawal.

Enter the date you signed this form (month, day, year).

Enter your current telephone number, including area code.

Enter your mailing address, including street number and name, apartment or P.O. Box, or rural route.

Enter the city and state where you currently reside.

Enter the ZIP Code corresponding to your mailing address.

Enter the name of the county in which you now live, if any.

Enter the type of Social Security benefit you want to withdraw (for example, retirement, disability, or survivor).

Enter the date of the original benefit application you are requesting to withdraw.

Check this box if you want to keep Medicare benefits when withdrawing your application.

Check this box if you do not want to keep Medicare benefits when withdrawing your application.

Enter the signature of the first witness who witnessed the applicant’s mark.

Enter the first witness’s full address, including number and street, city, state, and ZIP code.

Enter the internal tracking code assigned by the Social Security Administration to identify this application withdrawal request.

This field contains a detailed explanation of the legal basis for collecting your information, the voluntary nature of providing it, and how it may be used or shared. No input is required.

This field contains the Paperwork Reduction Act Statement, which explains the estimated time to complete the form and where to send it. No input is required.

Click this button to visit the Social Security Administration's privacy policy page.

Enter the full signature of the second witness who witnessed the applicant signing this form.

Provide the number and street, city, state, and ZIP Code of the second witness.

Sign here to complete the withdrawal request.

Check this box if the Social Security Administration approves your request to withdraw the application.

Check this box if the Social Security Administration does not approve your withdrawal request and specify the reason.

Check this box if the withdrawal request is not approved because benefits paid on the application have not been repaid.

Check this box if the withdrawal request is not approved because required consents were not obtained.

Check this box if the withdrawal request is not approved for another reason and attach a special determination.

Check this box if the withdrawal request is not approved for a different reason and specify that reason in the provided field.

Enter the signature of the Social Security Administration official authorizing the withdrawal.

Check this box if the authorizing SSA official’s title is Claims Specialist.

Enter the date the SSA official signed the authorization.

Check this box if you plan to continue working and still wish to withdraw your application after being advised of the alternatives to withdrawal.

Check this box if your reason for withdrawal is not covered by the other options and you will explain it fully in the space provided.

Provide a detailed explanation of your reason for withdrawing your application. Fill only if the 'Other (Please explain fully)' is 'Yes'.

Check this box to indicate that you have provided extra explanation on additional remarks pages.