Social Security Administration

Fill out Form SSA-521 online

Request for Withdrawal of Application

Form SSA-521 is a written request asking Social Security to withdraw (cancel) an application for benefits. If Social Security approves it, the decision on that application has no legal effect: you lose the rights that came with it, including appeal rights, and any payment made on it to you or anyone else must be returned. If you want benefits later, you have to apply again.

Fill out Form SSA-521 Blank form from the SSA

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Edition: (07-2026)
Pages: 2
Fillable fields: 37
Checked against the SSA: November 8, 2026

GuruPDF is not affiliated with the Social Security Administration. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses Form SSA-521

People who applied for Social Security benefits and want to cancel that application
People getting retirement benefits who want to undo their claim within the 12-month limit
People who plan to keep working and want to withdraw their application
People who applied on another worker's record, such as a spouse, and want to withdraw their own application

Before you start

The name and Social Security number of the worker (wage earner, self-employed individual or eligible individual) the application was filed on
Your own name and Social Security number, if you are not that worker
The type of benefit you want to withdraw and the date of the application
Your answer on whether you want to keep Medicare, if Medicare is part of the claim
A full explanation of why you want to withdraw
Your phone number, mailing address and the county you live in

How to fill out Form SSA-521

Read the important notice
The notice at the top of page 1 explains what withdrawal means: the decision on your application will have no legal effect, you give up the rights attached to it, including appeal rights, and you must return any payment made to you or anyone else on that application. A later application may not cover the same past period.
Names and Social Security numbers
Enter the name and Social Security number of the wage earner, self-employed individual or eligible individual. If you are a different person, for example a spouse who applied on the worker's record, print your own name (first name, middle initial, last name) and your own Social Security number on the next line.
Benefit, application date and Medicare
Write the type of benefit you want to withdraw and the date of the application. If Medicare applies, check Yes or No to say whether you want to keep Medicare benefits. Social Security's manual says a person 65 or older can withdraw monthly retirement or survivors benefits and keep Part A, but withdrawing a disability application also ends the Medicare based on it.
Read the statement and give your reason
The statement says the request cannot be canceled more than 60 days after the notice of approval is mailed, that all benefits paid on the application must be repaid, and that others whose benefits are affected must consent. Then check reason 1 if you intend to continue working (it also says you were told about the alternatives to withdrawal for applicants under full retirement age), or reason 2 (Other) and explain fully.
Page 2: sign and add your contact details
Page 2 starts with a declaration under penalty of perjury that the information is true. The person making the request signs in ink and enters the date (MM/DD/YYYY) and a telephone number with area code. Then fill in the mailing address, city, state, ZIP code and the county you live in now, if any.
Witnesses, only if signed by mark
Witnesses are needed only if the request is signed with a mark (X). In that case, two people who saw the signing and know the person making the request sign and write their full addresses. Leave the section For Use of Social Security Administration blank.

After you fill it out

Send or bring the signed form to your local Social Security office. Use the office locator on SSA.gov to find it. Social Security also has its own online version of Form 521 that you can fill out and submit after signing in to your account on SSA.gov. Social Security mails a notice when it approves the request.

Signing: The person making the request signs page 2, and the form says to write in ink, so print the form and sign it by hand. If it is signed with a mark (X), two witnesses who know that person must also sign and give their full addresses.

Watch out for

Before Social Security approves the withdrawal, all benefits paid on the application must be repaid, including money paid to family members and money withheld for Medicare premiums, taxes and garnishments. If you also withdraw Medicare, Part A costs Medicare paid for you must be repaid too.
Everyone whose benefits would end because of the withdrawal must agree in writing before Social Security can approve it.
For retirement benefits, Social Security's manual says the request must be made within 12 months of the first month of entitlement, and only one retirement withdrawal is allowed in a lifetime.
The request must be in writing. Social Security's manual says it does not treat a spoken request as a withdrawal request, and a faxed request does not meet the signature requirement.

Questions about Form SSA-521

Can I change my mind after I send Form SSA-521?

Only for a limited time. The form says the request cannot be canceled more than 60 days after Social Security mails the notice that it was approved.

Can I keep Medicare if I withdraw my application?

The form asks whether you want to keep Medicare. Social Security's manual says a person 65 or older can withdraw monthly retirement or survivors benefits and keep Part A, but withdrawing a disability application ends the Medicare based on it.

Can I apply for benefits again later?

Yes. You must file a new application, and the form warns that it may not cover the same past period as the one you withdrew.

Does withdrawing change my earnings record?

No. The form says the withdrawal does not affect how your wages or self-employment income are credited to your earnings record. The withdrawn application stays in Social Security's records.

Is there a time limit to withdraw?

For retirement benefits, Social Security's manual says the request must be made within 12 months of the first month of entitlement, and only once in a lifetime. For other benefit types, the manual says a withdrawal can be requested at any time.