SSA-21 - U.S Resident, MCS Macros Version

(1)Dates of U.S. presence of 30 days or more up to 3 occurrences

(mm/dd/yy-to-mm/dd/yy):

(2)Do you claim to be a U.S. resident for income tax purposes? Y/N:

(If No: go to #3) (If Yes: Do you understand that as a U.S. resident,

your worldwide income is subject to U.S. income tax? Y/N:

Have you been lawfully admitted for permanent residence? Y/N:

--If No: explain why you are a U.S. resident:

--If yes: Do you agree to notify SSA if you formally abandon or the U.S.

government takes away your U.S. residency, or you begin to be treated as a

resident of a foreign country under the provisions of a tax treaty between

the U.S. and that country? Y/N: ,Alien Registration #: )

(3)Do you claim a reduced rate of withholding under the provisions of an

income tax treaty with the U.S.? Y/N:

--If Yes: Name of country: