Free Request for Withdrawal of Application - SSA-521 2025

1. Click ‘Get Form’ to open the Free Request for Withdrawal of Application - SSA-521 in our editor.
2. Begin by entering the name of the wage earner or eligible individual in the designated field, followed by their Social Security number.
3. If applicable, provide your name and Social Security number if it differs from the wage earner's information.
4. Indicate whether you wish to keep your Medicare benefits by selecting 'Yes' or 'No'.
5. In the section requesting reasons for withdrawal, clearly state your reasons. If more space is needed, refer to the additional remarks section.
6. Sign and date the form where indicated. Ensure that your signature is written in ink.
7. If signed by mark (X), two witnesses must sign below, providing their full addresses.
8. Review all entered information for accuracy before saving and exporting your completed form.

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