TN 13 (07-17)

The field office (FO) has jurisdiction of a WD request submitted before the adjudication of the application. To process a WD request, the claimant must:

• The claimant must submit a request to withdraw a benefit application in writing, preferably via form SSA-521 (Request for Withdrawal of Application). The withdrawal request must include the specific class of benefit(s) he or she wants to withdraw and include a clear explanation as to why he or she is requesting the WD. We will not treat an oral request as a request for WD.

• The claimant must be alive at the time she or he files the WD request, except as shown in paragraph GN 00206.005B in this section.

For situations where an applicant fails to submit the required evidence to adjudicate a claim (e.g. marriage certificate), deny the application, as failing to submit evidence is not a WD request. For more information on denials, see GN 01010.400.

For situations where the applicant files an application (i.e. signs or attests the application), provides the required evidence, and then decides not to pursue the application (i.e. wants to withdraw the application), follow the steps in GN 00206.011A.

NOTE: A pre-adjudication RIB WD request will not count as the one-per-life RIB withdrawal.

A. Process for WD request before adjudication

• Obtain a signed and dated form SSA-521 (Request for Withdrawal of Benefits) or a written WD request noting the reason for WD, and determine if the claimant wants to withdraw all benefits (e.g. Retirement Insurance Benefit (RIB) and Medicare).

• Annotate the Report of Contact (RPOC) screen in the Modernized Claims System (MCS) (see MS MCS 008.007) describing the request for WD and include the date the NH signed the request.

• Award benefits that are not included on the WD (if any) (e.g. retaining the Medicare entitlement but withdrawing RIB).

• Annotate approval in the lower portion of the SSA-521.

• Enter the appropriate code for WD on the Decision Input (DECI) screen (see MS MCS 009.013) and process the WD request. For withdrawal codes, see SM 00380.040.

• Fax the signed statement and any related documentation into the Non-Disability Repository for Evidentiary Documents (NDRed).

NOTE: If you are unable to obtain the form SSA-521, document the follow up attempts and adjudicate the application as if the claimant had not requested the WD. For follow up procedures, see GN 01010.410C.

B. WD request involving Supplemental Security Income (SSI)

SSI applicants and recipients must take all steps necessary to apply for and obtain all possible Title II benefits available. Ensure the claimant understands he or she must file for and obtain all benefits or SSI eligibility will terminate. Follow the instructions below if the WD request involves SSI:

• Inform the claimant that a WD affects eligibility for SSI; see Overview of the Filing for Other Program Benefits Requirement in SI 00510.001.

• obtain a signed statement on an SSA-795 form (Statement of Claimant or Other Person), clearly stating that the claimant requesting WD of a Title II application is aware of the effect of a WD on SSI eligibility;

• process the WD request following the instructions in subsection A of this section;

• annotate the Report of Contact (DROC) screen in the Modernized Supplemental Security Income Claims System (MSSICS) (see MS MSSICS 022.010);

• notify FO personnel who are responsible for administering SSI of the WD request according to local FO procedure; and

• instruct him or her to take proper action to deny the SSI application or cease eligibility to existing SSI benefits if found eligible for other benefits per SI 00510.001B.6.

C. Conditional WD request involving Disability Insurance Benefits (DIB)

An applicant who is potentially eligible for more than one type of benefit (e.g. (RIB) and Disability Insurance Benefits (DIB)) has the option to withdraw the lower benefit payment upon the approval of the second benefit if the applicant filed separate applications. If the applicant is filing simultaneously for both benefits and wants to submit a conditional WD, follow the instructions in GN 00206.055B.1. A conditional WD is different from conversion cases. For information about conversion cases, see GN 00206.055B.1.

D. References

• GN 00204.007 Application Filing Date

• GN 00204.020 Scope of the Application

• GN 00206.005 Requirements for Withdrawal (WD) of a Benefit Application

• GN 00206.055 Conditional Withdrawals (WDs)

• GN 00206.145 Notice of Withdrawal (WD) and Appeal Rights

• GN 01010.027 District Office Final Authorization (DOFA) Exclusions

• GN 01010.400 Claim Denials

• SI 00510.001 Overview of the Filing for Other Program Benefits Requirement

• SI 00510.010 Pensions and Certain Compensation Programs as Potential Sources of Other Benefits