Form SSA-521 at a glance
What it is: Form SSA-521 is the Request for Withdrawal of Application of the Social Security Administration.
Who signs: Signature of person making request: Signature (First name, middle initial, last name) (Write in ink).
This is a request to withdraw your application.
A filled-in Form SSA-521 example: a worker withdraws a retirement application
How to fill out Form SSA-521, box by box
Name of Wage Earner, Self-Employed Individual, or Eligible Individual
Enter the Name of Wage Earner, Self-Employed Individual, or Eligible Individual and the Social Security Number.
If Different, Print your Name (First name, middle initial, last name) and Your Social Security Number.
Type of Benefit You Want to Withdraw
Enter the Type of Benefit You Want to Withdraw and the Date of Application.
If Applicable, Do You Want to Keep Medicare Benefits? Yes No.
Give reason for withdrawal
If a determination of your entitlement has been made, there must be repayment of all benefits paid on the application you want withdrawn, and all other persons whose benefits would be affected must consent to this withdrawal.
Give reason for withdrawal.
Box 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.)
Box 2: Other (Please explain fully).
Date, Telephone Number and Mailing Address
You declare under penalty of perjury that you have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of your knowledge.
Enter the Date (MM/DD/YYYY) and the Telephone Number (include area code).
Enter the Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route), City, State and ZIP Code, and Enter Name of County (if any) in which you now live.
Witnesses
Witnesses are required ONLY if this request has been signed by mark (X).
If signed by mark (X), two witnesses to the signing who know the person making the request must sign, giving their full addresses.
1. Signature of Witness. 2. Signature of Witness. Address (Number and Street, City, State and ZIP Code).
More rules for Form SSA-521
If Social Security approves it, the decision Social Security 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 Social Security 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.
The application withdrawn and all related material will remain a part of the records of the Social Security Administration and this withdrawal will not affect the proper crediting of wages or self-employment income to your Social Security earnings record.
It is estimated that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions.
Common questions about Form SSA-521
Is there a deadline?
This request may not be canceled after 60 days from the mailing of notice of approval.
Where do I file it?
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 also 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).
Is there a penalty?
Anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment.
When is this form not the right one?
Social Security intends 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.
Sources
[1] Form SSA-521 (07-2026), Request for Withdrawal of Application, Social Security Administration (the Official source link on this page).
