Request For Withdrawl Of Application
ADVERTISEMENT
1
2
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4SOCIAL SECURITY ADMINISTRATION
REQUEST FOR WITHDRAWAL OF APPLICATION
Do
not
write
in
this soace
IMPORTANT
NOTICE
-
This
is
a
request
to
cancel
your
application. lf
it
is approved,
the
decision we
made on your application
will
have no legal effect,
all
rights attached
to
an application, including
the
rights
of
reconsideration, hearing, and appeal
will
be forfeited, and any payments
we
made to you or
anyone
else
on
the
basis of
that
application
will
have
to
be
returned. You
must
then
reapply
if
you want
a determination of your Social Security rights at
any
time
in
the future but
any
subsequent
application
may not
involve
the same retroactive
period. This
procedure
is
intended
to
be used only when 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 Non-taxpayer:
Robert Vincent
Crifasi
(without prejudice, U.C.C
1-308)
PRf
NT YOUR NAME fFlrst name,
niddte initial,
tast
name)
Without
prejudice, U.C.C
Sect.
1-308
Robert V. Grifasi
Form Approved
TOE42O
OMBNo.0960-0015
bNL
Z-
TYPE OF BENEFIT
Social Security
Number
&
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withdrawn,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withdrawn and all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
self-employment
income
to
my
social
Security
earnings
record.
Give reason for
withdrawal.
(lf
you
need
more space,
use the
reverse of
this farm.)
.
-
| intend to continue
working. (l
have been advised of
the
alternatives to withdrawal for
applicants
under age
65
and still
wish
to
1.
"
withdraw
my
application.)
2'
X
Other (Please exPlain fully):
The
original SS-5
application
is
void due to coercion of my signature
when
I
was
incompetent, being
underage
to make
a
fully
understood valid election to apply for
the SS
program.
I
was
not
in
full
understanding of the voluntary
nature of benefit program when
the
application
was signed
in
approx 1965. Those
in authority
did
not
fully
disclose the
terms
of
the
agreement to
me.
I
was compelled to sign the SS-5 and
submit
by school
authorities.
X
Continued on
reverse
SIGNATURE OF PERSON MAKING REQUEST
Signature
(First name, middle
name,
last
name) (Write
in
ink)
All explicit
Rights reserved without
prejudice
UCC
i-308
Mailing Address (Number
and
street,
Apt.
No.,
P.o.
Box,
ar Rurlt
Route)
alt
rights
reserved
without
Nejudice,
uCC
i-3ag
NOTE: General Post,
in
care
of.
42900 Nido'Court
c
AT"
Date (Month, day, year)
February
18,
anno Domini2006
Telephone Number (rnclude area code)
510,677.7189
DATE OF APPLICATION
City and State I.,CC1308
Enter name of County (if any)
in
which you now live UCC1308
F
California
ut
preiudice)
-
Alameda
WitnessesarerequiredoNLYifthisrequesthasbeensigne
to
the
signing
who
know the person making the request must
sign
below, giving
theirfull
adbresses.-
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)
E
APPRoVED
SIGNATURE OF
fl
CoNSENT(S)
NOT
OBTAINED
I Ofnen
(Aftachspecial
determination)
ZIP Code
UCe
1-3S8
94539 / tdc
FOR USE OF SOCIAL SECURITY ADMINISTRATION
TITLE
n
CLAIMS
!
OTHER (Specrfy)
AUTHORIZER
Form
SSA-521
(1
1-1985)
EF (5-2000)
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