SSDI ‘1 for 2’ Project
Withdrawal Form
Name ____________________________Social Security #______________________ Date of Birth_____________
I would like to withdraw from the Utah SSDI ‘1 for 2’ Project effective immediately.
I understand that if I am in the Pilot Rules Gr
oup
and I withdraw from the Project, my enrollment
in the Project will end, and I will be subject to the usual SSDI program rules.
This will be effective
beginning with the first day of the month following the month I sign this form to withdraw. I understand
that this means I will no longer be eligible for the medical CDR protection and the gradual benefit
reduction.
I understand that if I am in the Current Rules Gr
oup, I will remain on SSDI, if eligible, and
I will
be subject to the usual SSDI program rules.
I understand once I withdraw from the project, I can not reen
roll
in the project.
I understand that the SSDI ‘1 for 2’ project team is no longer authorized to collect any additional data on
me. The ‘1 for 2’ project team may still use any of the data that has already been collected.
Participant’s Signature
Date
( ) -
Street, City, State, Zip Code
Telephone
To help us better evaluate the effectiveness of this project, please mark one item below indicating
why you are withdrawing from the project:
1 ____
I am not happy with my group assignment (either current rules or pilot rules)
2 ____
I do not want to comply with requirements of the project such as surveys, notifying project of
address changes.
3 ____
I am concerned about over- and under-payments from SSA
4
___
I am concerned about changes to non-SSA public benefits
5
___
I am concerned about getting benefits again if unable to work in the future
6
___ I am no longer able to work or interested in working
7
___ I choose not to participate
8
___ Other, please specify:____________________________________
9
___ I do not want to answer this question.
Please return this form to:
Utah SSDI ‘1 for 2’ Project, 1595 West 500 South, Salt Lake City, UT 84104
Fax: (801) 887-9389