Form SSA-521 Request for Withdrawal of Application

What Is Form SSA-521?

Form SSA-521, Request for Withdrawal of Application is a form used to cancel the application for Social Security benefits you submitted.

The document was issued by the Social Security Administration (SSA). The latest version of the form - also known as the SSA Form 521 - was released by the SSA in November 2018 with previous editions obsolete. An SSA-521 fillable form can be downloaded below.

Form SSA-521-SP, Solicitud Para Revocar Una Reclamación - used to submit the SSA request for withdrawal of the application you submitted - is a Spanish version of the original form.

What Is Form SSA-521 Used for?

​If after applying for Social Security Retirement benefits you have changed your mind about when to start them, you can withdraw your claim by submitting Form SSA-521. The withdrawal can be requested even if you have been receiving your benefits for some time. The information you provide via the form is used by the SSA officials to determine whether you are eligible for a cancellation of benefits. If you provide incomplete information, it may result in rejection of your application.

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Form SSA-521 (11-2018) UF
Discontinue Prior Editions
Page 1 of 2
Social Security Administration
OMB No. 0960-0015
TOE 420
REQUEST FOR WITHDRAWAL OF APPLICATION
Do not write in this space
IMPORTANT NOTICE - This is a request to withdraw your application. If we approve it, the
decision we made on your application will have no legal effect. You will forfeit all rights attached
to an application, including the rights of appeal. You will have to return any payment we made to
you or anyone else on the basis of that application. You must then reapply if you want a
determination of your Social Security rights at any time in the future. Any subsequent application
may not involve the same retroactive period. We intend for you to use this procedure only when
your decision to file has resulted, or will result, in a disadvantage to you. Your local Social
Security office will be glad to explain whether, and how, this procedure will help you.
NAME OF WAGE EARNER, SELF-EMPLOYED INDIVIDUAL, OR ELIGIBLE
SOCIAL SECURITY NUMBER
INDIVIDUAL
IF DIFFERENT, PRINT YOUR NAME (First name, middle initial, last name)
YOUR SOCIAL SECURITY NUMBER
TYPE OF BENEFIT YOU WANT TO WITHDRAW
DATE OF APPLICATION IF APPLICABLE, DO YOU WANT TO KEEP
Yes
No
MEDICARE BENEFITS?
I hereby request the withdrawal of my application, dated as above, for the reasons stated below. I understand that (1) this request
may not be cancelled after 60 days from the mailing of notice of approval; and (2) if a determination of my entitlement has been
made, there must be repayment of all benefits paid on the application I want withdrawn, and all other persons whose benefits
would be affected must consent to this withdrawal. I further understand that the application withdrawn and all related material will
remain a part of the records of the Social Security Administration and that this withdrawal will not affect the proper crediting of
wages or self-employment income to my Social Security earnings record.
Give reason for withdrawal. (If you need more space, use the reverse of this form.)
I intend to continue working. (I have been advised of the alternatives to withdrawal for applicants under full retirement
1.
age and still wish to withdraw my application.)
2.
Other (Please explain fully):
Continued on reverse
SIGNATURE OF PERSON MAKING REQUEST
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, day, year)
SIGN
Telephone Number (include area code)
HERE
Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)
City and State
ZIP Code
Enter Name of County (if any) in which you now live
Witnesses are required ONLY if this request has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the person making the request must sign below, giving their full addresses.
1. Signature of Witness
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
Address (Number and Street, City, State and ZIP Code)
FOR USE OF SOCIAL SECURITY ADMINISTRATION
NOT APPROVED
BENEFITS NOT
CONSENT(S) NOT
OTHER
APPROVED
BECAUSE
REPAID
OBTAINED
(Attach special determination)
OTHER (Specify)
SIGNATURE OF SSA EMPLOYEE
TITLE
DATE
CLAIMS
AUTHORIZER
Form SSA-521 (11-2018) UF
Discontinue Prior Editions
Page 1 of 2
Social Security Administration
OMB No. 0960-0015
TOE 420
REQUEST FOR WITHDRAWAL OF APPLICATION
Do not write in this space
IMPORTANT NOTICE - This is a request to withdraw your application. If we approve it, the
decision we made on your application will have no legal effect. You will forfeit all rights attached
to an application, including the rights of appeal. You will have to return any payment we made to
you or anyone else on the basis of that application. You must then reapply if you want a
determination of your Social Security rights at any time in the future. Any subsequent application
may not involve the same retroactive period. We intend for you to use this procedure only when
your decision to file has resulted, or will result, in a disadvantage to you. Your local Social
Security office will be glad to explain whether, and how, this procedure will help you.
NAME OF WAGE EARNER, SELF-EMPLOYED INDIVIDUAL, OR ELIGIBLE
SOCIAL SECURITY NUMBER
INDIVIDUAL
IF DIFFERENT, PRINT YOUR NAME (First name, middle initial, last name)
YOUR SOCIAL SECURITY NUMBER
TYPE OF BENEFIT YOU WANT TO WITHDRAW
DATE OF APPLICATION IF APPLICABLE, DO YOU WANT TO KEEP
Yes
No
MEDICARE BENEFITS?
I hereby request the withdrawal of my application, dated as above, for the reasons stated below. I understand that (1) this request
may not be cancelled after 60 days from the mailing of notice of approval; and (2) if a determination of my entitlement has been
made, there must be repayment of all benefits paid on the application I want withdrawn, and all other persons whose benefits
would be affected must consent to this withdrawal. I further understand that the application withdrawn and all related material will
remain a part of the records of the Social Security Administration and that this withdrawal will not affect the proper crediting of
wages or self-employment income to my Social Security earnings record.
Give reason for withdrawal. (If you need more space, use the reverse of this form.)
I intend to continue working. (I have been advised of the alternatives to withdrawal for applicants under full retirement
1.
age and still wish to withdraw my application.)
2.
Other (Please explain fully):
Continued on reverse
SIGNATURE OF PERSON MAKING REQUEST
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, day, year)
SIGN
Telephone Number (include area code)
HERE
Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)
City and State
ZIP Code
Enter Name of County (if any) in which you now live
Witnesses are required ONLY if this request has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the person making the request must sign below, giving their full addresses.
1. Signature of Witness
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
Address (Number and Street, City, State and ZIP Code)
FOR USE OF SOCIAL SECURITY ADMINISTRATION
NOT APPROVED
BENEFITS NOT
CONSENT(S) NOT
OTHER
APPROVED
BECAUSE
REPAID
OBTAINED
(Attach special determination)
OTHER (Specify)
SIGNATURE OF SSA EMPLOYEE
TITLE
DATE
CLAIMS
AUTHORIZER
Form SSA-521 (11-2018) UF
Page 2 of 2
Additional Remarks:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 205, 223 and 1872 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide us with all or part of the information may cause continued consideration of
your benefits claim.
We will use the information you provide to cancel your application for benefits. We may also share your information for the
following purposes, called routine uses:
• To student volunteers and other workers, who technically do not have the status of Federal employees, when they are
performing work for Social Security Administration (SSA) as authorized by law, and they need access to personally
identifiable information in SSA records in order to perform their assigned agency functions; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs.
In addition, we may share the information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims Folders
Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional information and a full listing of all
our SORNs are available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
- This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You
can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are listed under U.S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Download Form SSA-521 Request for Withdrawal of Application

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Form SSA-521 Instructions

  • You may withdraw your application within twelve months from the date you were entitled to receive your Social Security benefits;
  • You are allowed to submit the withdrawal only once in your life;
  • You can cancel your withdrawal within 60 days after its approval;
  • If you have reached full retirement age, you are not allowed to withdraw your retirement application. However, if you are not yet age 70, you can ask the SSA to suspend your benefit payments;
  • If your withdrawal is approved, you must repay all of the money you and your family received due to the retirement application;
  • If anyone receives benefits based on your application, this individual must also provide written consent to the withdrawal;
  • You may withdraw your Medicare with your Social Security benefits, or you may keep your Medicare coverage.

How to Fill out Form SSA-521?

​The document is easy to complete. It takes about five minutes to look through the instructions, gather information, and find the answers. Follow the steps below in order to fill out the form correctly:

  1. Enter the name of the individual entitled to receive Social Security benefits;
  2. Indicate the Social Security number (SSN) of the eligible individual;
  3. If you are not the person entitled to Social Security benefits, provide your full name including middle initial;
  4. Indicate your SSN;
  5. Specify the type of benefits you wish to withdraw;
  6. Enter the exact date of application for these benefits;
  7. Check the applicable box to specify if you want to keep your Medicare coverage;
  8. Explain the withdrawal reason. If you want to continue working, choose Box 1. Otherwise, check Box 2 and provide a detailed explanation of your decision. If the space provided is not enough, continue on the reverse side. Do not forget to check "Continued on Reverse" Box;
  9. Sign the document. Write your first name, middle initial, and last name in ink;
  10. Enter the date in MMDDYYY format;
  11. Provide the phone number you can be reached at, including area code;
  12. Indicate your full mailing address, including city, state and ZIP code;
  13. Enter the name of the county in which you reside at present;
  14. If you have signed this document with "X", you will need two witnesses who know you to sign the document. Besides the signatures, these witnesses will have to provide their full mailing addresses including ZIP code;
  15. Leave the remaining fields blank. They must be filled out by the SSA officials only.

It may take from a few weeks to a few months to process the completed form. After approving the withdrawal, the SSA will inform you about the exact amount you need to repay and the schedule of repayments.

Where Do I Send Form SSA-521?

Send or bring the filled-out SSA Form 521 in person to the nearest Social Security office. Find a list of all offices on the SSA official website. Besides, you can check them up in your telephone directory in the U.S. Government agencies section.

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