Ssa-21,

Form A roved
OMB NO.09R-0051
SOCIAL SECURITY ADMINISTRATION
SUPPLEMENT TO CLAIM OF PERSON OUTSIDE THE UNITED STATES
(To be completed by or on behalf of person who is, was, or will be outside the U.S.)
For Social Security purposes, a person is outside the United States if he or she is physically outside the 50 States, the District of
Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana lslands,or ~ i e r i c a nSamoa.
2. WORKER'S SOCIAL SECURITY NUMBER
1. NAME OF WORKER ON WHOSE EARNINGS THIS CLAIM IS BASED

-

LlST BELOW THE FULL NAME OF THE
WORKER (EVEN IF DECEASED) AND OF
EACH BENEFICIARY IN THE SAME
HOUSEHOLD WHO IS, WAS OR WILL BE
F UNITFO STATFS

3.

COUNTRY WHERE
YOU LIVE

COUNTRY
OF
BlRTH

OVER NEXT 12
MONTHS

PRESENT

COUNTRY IES) OF
PREsLNT
ClTlZENSHlP
(Or at time of death)

-

IF PERSON HAS U.S.
PASSPORT, LIST:

PAS^^^

DATE ISSUED

a.
b.
C.
d.
Note: All persons listed above or their re~resentativepayees must sian the certification in item 18.
4. If any beneficiary listed in item 3 was outside the U.S. this month or any of the past 24 months, or will be in the next 6 months,
corn lete item 4 by entering the name of the beneficiary and dates (month, day and year he or she was or will be outside the U.S.
NO~E,:Entries should not be made by residents of Canada or Mexico who are entering tAe U.S. on a daily basis to work or visit and
returning each day to their residence In Canada or Mexlco.
DATE OF EXPECTED
OUTSIDE U.S.
OUTSIDE U.S.
RETURN TO U.S. (If within the
NAME
FROM
TO
TO
FROM
next 18 months)
Mo-Dav-Yr
Mo-Dav-Yr
Mo-Day-Yr
Mo-Dav-Yr

a.

I

I

I

I

I

5. Has any person listed in item 3 been employed or self-employed outside the U.S. during any of the
i
yes
past 12 months? If "yes," give name and date(s) work began.
NAME
DATE(S)

NO

-,++

I

NAME

DATE(S)

6. Does any person listed in item 3 expect to begin employment or self-employmentoutside the U.S.
in the future? If "yes," give name and date(s) work is expected to begin.
DATE
NAME
NAME

WORKER AND OF EACH

NO. OF RELATIONSHIP TO
YRS. WORKER NAMED IN
LIVED ITEM 1 DURING THIS
IN U.S.
PERIOD

C] NO

yes

DATE

DATES PERSON LIVED IN THE U.S.
FROM

Mo-Day-Yr

TO

Mo-Day-Yr

FROM
Mo-Day-Yr

TO
Mo-Day-Yr

If you need more space, use "REMARKS" on page 3.
8. Answer item 8 only if the worker named in item 1 is deceased.
Did the worker die while in the military service of the U.S. or as a result of disease or injury incurred
C] Yes
NO
C
or aggravated in the military service?
g, Supplementary Mediwl Insurance generally is pa able only for medic4 services provided inside the United States. If anyone listed in
Item 3 IS now enrolled In Supplementary Medlcal Lsurance under Medlcare and w~shesto termlnate that enrollment, enter his or her
name here.
NAME(S)
Form SSA-21 (3-2006)

ef (3-2006)

Destroy prior editions

Page I

IF EVERYONE LISTED IN ITEM 3 IS A U.S. CITIZEN, SKIP ITEMS 10 THROUGH 14 AND GO TO ITEM 15.
The U.S. lnternal Revenue Code (IRC) requires the Social Security Administration (SSA) to withhold a 25.5 percent Federal income tax
from the monthly benefits paid to beneficiaries who are neither citizens nor residents of the U.S. The tax is withheld from the benefits of all
nonresident aliens except those who reside in countries that have tax treaties with the U.S. that do not permit the taxing of U.S. Social
Security benefits or that provide for a lower tax rate.
For Federal income tax purposes, a person can be considered a U.S. resident, even if that person lives outside the US., if he or she:
Has been lawfully admitted to the U.S. for permanent residence and that residence has not been revoked or administratively or
judicially determined to have been abandoned; or
Meets a substantial presence test. To meet this test in a given year, the person must be present in the U.S. on at least 31 days in
that year, and the total number of days he or she was in the U.S. during that year and the previous two years must be at least 183
days as determined by the provisions of the IRC.
The Internal Revenue Service taxes the world-wide income of a U.S. resident who is living outside the U.S. in the same way that it taxes
the income of a person living in the U.S. A person cannot be considered a U.S. resident in any year for which he or she has claimed a tax
treaty benefit as a resident of a country other than the U.S.
COMPLETE ITEMS 10 THROUGH 14 ABOUT ALL PERSONS LISTED IN ITEM 3 WHO ARE NOT U.S. CITIZENS AND WHO WANT TO
BE CONSIDERED U.S. RESIDENTS FOR TAX PURPOSES.
10. Enter below the name of all persons listed in item 3 who believe they will have U.S resident status while living outside the U.S. Also
show the number of each person's Permanent Resident Card (sometimes referred to as a Green Card) and the date that card was
issued. If any person was not lawfully admitted for permanent residence, show "None" and explain why he or she is a U.S. resident in
"REMARKS" on page 3.
NAME

PERMANENT RESIDENT CARD
(GREEN CARD) NUMBER

DATE CARD WAS ISSUED

11. Has any person listed in item 10 ever notified the Department of Homeland Security (DHS), formerly
the U.S. Immigration and Naturalization Service (INS), by letter or formal application that he or she is,
or was, abandoning his or her U.S. residence?

Dyes

q NO

If "yes," enter below the name of the person(s) and the date such notice was given.

NAME

DATE (MONTH AND
YEAR) NOTICE WAS
GIVEN TO DHSllNS

DATE (MONTH AND YEAR)
NOTICE WAS GIVEN TO
DHSllNS

NAME

12. Has any person listed in item 10 been notified by DHSIINS that he or she no longer has U.S. resident
status or has his or her Permanent Resident Card been taken by DHSIINS?

q yes q NO

If "yes," give the name of the person(s) and the date he or she was notified, or his or her card was
taken, by DHSIINS.

NAME

Form SSA-21 (3-2006) ef (3-2006)

DATE (MONTH AND
YEAR) OF NOTICE OR
DATE DHSllNS TOOK
THE CARD

NAME

Page 2

DATE (MONTH AND YEAR) OF
NOTICE OR DATE DHSllNS
TOOK THE CARD

-

13. Does each person listed in item 10 understand that, as a U.S. resident, his or her worldwide income
will be subject to U.S. income tax in the same way as the income of a person living in the U.S.?
Ilf "no," show the name(s) of that person(s) in "REMARKS" below.

14. Does each person listed in item 10 agree to notify SSA promptly if he or she abandons his or her U.S.
residence status, OR if that person is notified by DHS that his or her U.S. resident status has been
revoked or abandoned?

Yes

No

yes

El NO

If "no," show the name(s) of that person(s) in "REMARKS" below and the reason(s) that person(s)
does not agree to notify SSA.
REMARKS (You may use this space for any additions and explanations. If you need more space, attach a separate sheet.)

15. PAYMENT ADDRESS (Where payments should be sent while you are abroad. If your payments are, or will be, sent directly to a bank
or other financial institution, do not complete this item. Go to item 16.)
NUMBER AND STREET

CITY

POSTAL CODE

COUNTRY

NOTE: If more than one address is required, use "REMARKS" above and show names for each address.
16. MAILING ADDRESS (Where your mail should be sent while you are abroad. If it is the same as the address in item 15, enter "same
as 1 5 and go to item 17.)
NUMBER AND STREET

POSTAL CODE

CITY

COUNTRY

NOTE: If more than one address is required, use "REMARKS" above and show names for each address.
17. RESIDENCE ADDRESS (You must complete this item if you live, or will live, at an address other than the address shown in item 15 or
16. If the address where you live, or will live, is the same as the address in item 15 or 16, enter "same as 15 (or 16 if appropriate)" and
go to item 18.)
NAME

NUMBER AND STREET

CITY

POSTAL CODE

COUNTRY

a.
b.

C.

d.
NOTE: If your payments are not, or will not be, sent directly to a bank or other financial institution and you receive, or will receive,
them by mail at an address that is not your residence address, explain the reason in "REMARKS" above.

Form SSA-21 (3-2006) ef (3-2006)

Page 3

CERTIFICATION AND SIGNATURES
I agree to notify the Social Security Administration promptly if I (or any person for whom I receive benefits) become employed or self-employed while
outside the United States, change citizenship, or go (for 30 days or more) to any country other than that indicated in item 17. 1 also agree to return any

payments which are not due.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and
correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information.
or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

6~

SIGNATURE FIRST NAME, MIDDLE INITIAL AND LAST
NAME
EACH PERSON LISTED IN I ~ E M3.
REPRESENTATIVE PAYEES MUST SIGN FOR MINORS AND
FOR INCAPABLE OR INCOMPETENTADULTS. Write in ink.

DATE

TELEPHONE NUMBER WHERE YOU
MAY BE CONTACTED DURING THE DAY

C.

d.
Witnesses are required only if this application has been signed by mark (X) in item 18. If signed by mark (X), two witnesses who know the
signer(s) must sign below, giving their full addresses.
19. (1) SIGNATURE OF WITNESS
(2) SIGNATURE OF WITNESS
I

ADDRESS (NUMBER AND STREET)
CITY
I

ADDRESS (NUMBER AND STREET)

POSTAL CODE COUNTRY
I

I

POSTAL CODE COUNTRY

CITY
I

I

I

PRIVACY ACT STATEMENT

The Social Security Administration is authorized to collect information to establish your entitlement to Social Security benefits under section 202 of the
Social Security Act, as amended (42 U.S.C. 402 and 405). This information will also be used to verify your U.S. income tax status under sections 871
and 1441 of the Internal Revenue Code (26 U.S.C. 871 and 1441). While completing this form is voluntary, failure to provide all or part of this
information is cause for suspension of benefit payments. The information on this form may be disclosed by the Social Security Administration to
another person or agency for the following purposes: (1) to assist the Social Security Administration in establishing a person's right to Social Security
benefits, (2) to help with statistical research and audits necessary to assure the integrity and improvement of the Social Security programs, and (3) to
comply with laws requiring or allowing the exchange of information between the Social Security Administration and another agency.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other
Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the
Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you give us may be used or given out are available in Social Security offices. If you want
to learn more about this, contact any Social Security office.
PAPERWORK REDUCTION ACT STATEMENT

This information collection meets the requirements of 44 U.S.C. 5 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 1338 Annex
Building. Baltimore. MD 21235-6401. Send & comments relatitig to our time estimate to this address, not the completed form

Form SSA-21 (3-2006) ef (3-2006)

Page 4