REQUEST FOR WITHDRAWAL OF APPLICATION
Page 1 of 2
OMB No. 0960-0015
TOE 420
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.
Do not write in this space
NAME OF WAGE EARNER, SELF-EMPLOYED INDIVIDUAL, OR ELIGIBLE
INDIVIDUAL
SOCIAL SECURITY NUMBER
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
MEDICARE BENEFITS?
Yes No
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made, there must be repayment of all benefits paid on the application I want withdrawn, and all other persons whose benefits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 I further understand that the application withdrawn and all related material will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.)
1.
I intend to continue working. (I have been advised of the alternatives to withdrawal for applicants under full retirement
age and still wish to withdraw my application.)
2.
Other (Please explain fully):
Continued on reverse
SIGNATURE OF PERSON MAKING REQUEST
SIGN
HERE
Date (Month, day, year)
Telephone Number (include area code)
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
Address (Number and Street, City, State and ZIP Code)
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
FOR USE OF SOCIAL SECURITY ADMINISTRATION
APPROVED
NOT APPROVED
BECAUSE
BENEFITS NOT
REPAID
CONSENT(S) NOT
OBTAINED
OTHER
(Attach special determination)
SIGNATURE OF SSA EMPLOYEE TITLE
CLAIMS
AUTHORIZER
OTHER (Specify)
DATE
Form SSA-521 (11-2018) UF
Discontinue Prior Editions
Social Security Administration
Signature (First name, middle initial, last name) (Write in ink)
