Fillable Form SSA-521, 10-2012 - Request for Withdrawal of Application - Social Security Administration - ssa
Give reason for withdrawal. If you need more space use the reverse of this form. I intend to continue working. 1. Signature of Witness Address Number and Street City State and ZIP Code FOR USE OF SOCIAL SECURITY ADMINISTRATION APPROVED BECAUSE SIGNATURE OF SSA EMPLOYEE BENEFITS NOT REPAID CONSENT S NOT OBTAINED TITLE DATE CLAIMS AUTHORIZER Form SSA-521 10-2012 EF 10-2012 Destroy Prior Editions OTHER Attach special...
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