What is the Social Security form Ssa 521? This form is for individuals who are requesting a statement of their earnings and contributions to Social Security. It can be used to help you apply for retirement, disability, or survivors benefits. The Ssa 521 form is also known as the Statement of Earnings and Contribution Record. In order to complete the form, you will need your Social Security number and date of birth. Be sure to review the instructions carefully before completing the form. If you have any questions, please contact Social Security directly.
The table offers information regarding the social security form ssa 521. There, you'll discover the information about the form you would like to fill in, along with the approximate time to fill it out and also other data.
| Question | Answer |
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| Form Name | Social Security Form Ssa 521 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | social security form 521, ssa 521 form, withdrawal form, form ssa 521 social security |
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Discontinue Prior Editions |
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Page 1 of 2 |
Social Security Administration |
TOE 420 |
OMB No. |
REQUEST FOR WITHDRAWAL OF APPLICATION |
Do not write in this space |
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IMPORTANT NOTICE - This is a request to withdraw your application. If we approve it, the |
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decision we made on your application will have no legal effect. You will forfeit all rights attached |
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to an application, including the rights of appeal. You will have to return any payment we made to |
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you or anyone else on the basis of that application. You must then reapply if you want a |
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determination of your Social Security rights at any time in the future. Any subsequent application |
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may not involve the same retroactive period. We intend for |
you to use this procedure only when |
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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, |
SOCIAL SECURITY NUMBER |
INDIVIDUAL |
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IF DIFFERENT, PRINT YOUR NAME (First name, middle initial, last name) |
YOUR SOCIAL SECURITY NUMBER |
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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
Give reason for withdrawal. (If you need more space, use the reverse of this form.)
1.
2.
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.)
Other (Please explain fully):
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Continued on reverse |
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SIGNATURE OF PERSON MAKING REQUEST |
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Signature (First name, middle initial, last name) (Write in ink) |
Date (Month, day, year) |
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SIGN |
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Telephone Number (include area code) |
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HERE |
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Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route) |
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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
APPROVED |
NOT APPROVED |
BENEFITS NOT |
CONSENT(S) NOT |
OTHER |
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BECAUSE |
REPAID |
OBTAINED |
(Attach special determination) |
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SIGNATURE OF SSA EMPLOYEE |
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TITLE |
OTHER (Specify) |
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DATE |
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CLAIMS |
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AUTHORIZER |
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Form |
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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)
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
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