NL 00701.093 Form SSA-L250 — Approval of Withdrawal

A. Sample form

Social Security
Benefit Information

 

From:

 

Date:

Claim Number:

We have approved your request for withdrawal of your application for

You can cancel your withdrawal, if you choose to do so, by filing a written request with the Social Security Administration within 60 days after.

Your request for withdrawal affects only the application being withdrawn. You can later file a new application.

The application you filed could be used for other classes of benefits besides the one you withdrew. However, no entitlement exists to any other benefit based on the application you filed.

If you believe this determination regarding eligibility to any other type of benefit is not correct, you may request that your case be reexamined. The right to reexamination does not apply to your withdrawal request. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request through any social security office. If additional evidence is available, you should submit it with your request.

Department of Health and Human Services
Social Security Administration

SSA-L250
Destroy prior editions

B. Preparation of form

The source of information for completing the fill-ins for this form notice is the Form SSA-559, Transmittal Slip for Claims Folder.

Type the “Type of Benefit” as shown on Form SSA-559.

NOTE: The typist will automatically type paragraph 258 on this notice, unless dictated information or paragraph 257 is indicated on Form SSA-559.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900701093
NL 00701.093 - Form SSA-L250 -- Approval of Withdrawal - 06/11/2013
Batch run: 06/11/2013
Rev:06/11/2013