Form SSA-21 Supplement to Claim of Person Outside the United States

Form SSA-21 (XX-2017) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0051

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 (U.S.) 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 Islands, or American Samoa for 30
consecutive days or more.
1. NAME OF WORKER ON WHOSE EARNINGS THIS CLAIM IS BASED

2. WORKER'S SOCIAL SECURITY NUMBER

3. Complete line (a) below for the worker (even if deceased). Complete (b) through (d) for each claimant or beneficiary who is
not a U.S. citizen, and is outside the U.S., has been outside the U.S. in the past 24 months, or expects to be outside the
U.S. for 30 consecutive days or more. Enter only the claimants or beneficiaries living in the same household. Complete a
separate form for each household. If you need more space, use the “REMARKS” section on page 4.
COUNTRY(IES) OF PRESENT
FULL NAME
PASSPORT NO.
DATE ISSUED
CITIZENSHIP (Or at time of death)
a.
b.
c.
d.

FOR EACH WORKER LISTED ABOVE, CONTINUE TO LIST INFORMATION REQUESTED BELOW:
WORKER/PERSON LISTED ABOVE

COUNTRY
OF BIRTH

FROM
Mo-Day-Yr

DATES OUTSIDE THE U.S.
TO
COUNTRY WHERE
Mo-Day-Yr
LIVING

WORKER LISTED ABOVE IN ROW (a.)
PERSON LISTED ABOVE IN ROW (b.)
PERSON LISTED ABOVE IN ROW (c.)
PERSON LISTED ABOVE IN ROW (d.)

NOTE: ALL PERSONS LISTED ABOVE AND IN THE "REMARKS" SECTION ON PAGE 4, OR THEIR
REPRESENTATIVE PAYEES, MUST SIGN THE CERTIFICATION IN ITEM 18.
4. Complete line (a) for the worker (even if deceased). Complete (b) through (d) for each claimant or beneficiary listed in item
3 who is not a U.S. citizen. Do not include the days that residents of Canada or Mexico enter the U.S. on a daily basis to
work or visit and return each day to their residence in Canada or Mexico, as dates lived in the U.S. If you need more
space, use the “REMARKS” section on page 4.
TOTAL
DATES LIVED IN THE U.S.
NUMBER OF
RELATIONSHIP TO
FULL NAME
YEARS
FROM
TO
WORKER
NAMED IN ITEM 1
LIVED IN
Mo-Day-Yr
Mo-Day-Yr
DURING
THIS PERIOD
THE U.S.
a.
b.
c.
d.
5. Has any person listed in item 3 been employed or self-employed outside the U.S. during any
of the past 12 months? If "yes," give name(s) and date(s) work began and submit Form
SSA-7163 (available at www.socialsecurity.gov). If you need more space, use the
"REMARKS" section on page 4.
NAME
Date (Mo - Yr)
NAME

YES

NO
Date (Mo - Yr)

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

YES

NO

more space, use the “REMARKS” section on page 4.
NAME

Date (Mo - Yr)

Date (Mo - Yr)

NAME

7. Answer item 7 only if the worker named in item 1 is deceased. Did the worker die while in the
YES
NO
military service of the U.S. or as a result of disease or injury incurred or made worse while in
military service?
8. Supplementary Medical Insurance generally is payable only for medical services provided inside the U.S. If anyone listed in
item 3 is now enrolled in Supplementary Medical Insurance under Medicare and wishes to terminate that enrollment, enter
his or her name here. If you need more space, use the ”REMARKS” section on page 4.
NAME(S)
The U.S. Internal Revenue Code (IRC) requires the Social Security Administration (SSA) to withhold a 30 percent Federal
income tax from 85 percent of monthly retirement, survivors and disability benefits paid to beneficiaries who are neither
citizens nor residents of the United States. This results in an effective tax of 25.5 percent of the monthly benefit. SSA must
withhold this tax from the benefits of all nonresident aliens except those who are residents of countries that have tax treaties
with the U.S. that provide an exemption from this tax, or a lower rate of withholding. Currently these countries are Canada,
Egypt, Germany, India, Ireland, Israel, Italy, Japan, Romania, Switzerland, and the United Kingdom. For details and
changes regarding income tax treaties, you may check with the Internal Revenue Service.
For Federal income tax purposes, a person can be considered a U.S. resident, even if that person lives outside the United
States, if he or she:
• Has not claimed a tax treaty benefit as a resident of a country other than the United States in the same year; AND
• Has been lawfully admitted to the United States for permanent residence and that residence has not been revoked
or determined to have been administratively or judicially abandoned; OR
• Meets a substantial presence test as defined by the IRC. 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 a minimum total of 183 days counting all the days of U.S.
presence in that year, one-third of the total number of days of U.S. presence in the previous year, and one-sixth of
the total number of days of U.S. presence in the year before that. (The IRC defines days of U.S. presence and
exclusions for applying the substantial presence test.)
If you are a U.S. resident alien for Federal income tax purposes, generally your worldwide income is subject to U.S. income
tax, regardless of where you are living.

COMPLETE ITEMS 9 THROUGH 13 ABOUT ALL PERSONS LISTED IN ITEM 3 WHO ARE NOT U.S.
CITIZENS AND WANT TO BE CONSIDERED U.S. RESIDENTS FOR INCOME TAX PURPOSES.
9. 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 the "REMARKS" section on page 4.
NAME

PERMANENT RESIDENT CARD
(GREEN CARD) NUMBER

DATE CARD WAS
ISSUED

10. Enter the name(s) of any person(s) listed in item 9 who has ever notified the U.S. government, by letter or formal
application, that he or she has abandoned, or wishes to abandon, his or her U.S. residence status, or has commenced to be
treated as a resident of a foreign country under the provisions of a tax treaty between the U.S. and the foreign country.
NAME

Date (Mo-Yr)

NAME

Date (Mo-Yr)

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11. Enter the name(s) of any person(s) listed in item 9 whose Permanent Resident Card has been taken away, or who has
been notified by the U.S government that his or her U.S. resident status has been taken away. Enter the date of the notice
or the date the Permanent Resident Card was taken away.
NAME

NAME

Date (Mo-Yr)

Date (Mo-Yr)

12. Does each person listed in item 9 understand that, as a U.S. resident, his or her worldwide income will
be subject to U.S. income tax regardless of where he or she is living? If no, enter the name
of each individual who does not understand in the "REMARKS" section on page 4.

YES

NO

13. Does each person listed in item 9 agree to notify SSA promptly if he or she abandons his or her U.S.
residence status, or if he or she commences to be treated as a resident of a foreign country under the
provisions of a tax treaty between the U.S. and the foreign country? If no, enter the name of each
individual who does not agree in the "REMARKS" section on page 4.

YES

NO

14. INCOME TAX TREATY BENEFITS Complete this item for any person(s) who intend(s) to claim a reduced rate of Federal
income tax withholding under the provisions of an income tax treaty with the U.S. To enter additional person(s), use the
"REMARKS” section on page 4.
NAME

TAX TREATY COUNTRY
OF RESIDENCE

DATES OF RESIDENCE
FROM (Mo-Yr)

TO (Mo-Yr)

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.) If more than one address is required, use
the "REMARKS" section below and show names for each address.
NUMBER AND STREET

CITY

POSTAL CODE

COUNTRY

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 15" and go to item 17.) If more than one address is required, use the "REMARKS" section on page 4 and
show names for each address.
NUMBER AND STREET
POSTAL CODE
COUNTRY
CITY

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.) 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 the "REMARKS" section on page 4.
NAME
a.

b.

c.

d.

NUMBER AND STREET

CITY

POSTAL CODE

COUNTRY

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REMARKS (You may use this space for any additions and explanations. If you are giving information for a
particular item on this form, enter the item number in your remark. If you need more space, attach a separate
sheet.)

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. I also agree to return any payments which are not due.
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and
belief it is true, correct, and complete. 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.
18.

SIGNATURE (FIRST NAME, MIDDLE INITIAL, AND
LAST NAME) OF EACH PERSON LISTED IN ITEM 3.
REPRESENTATIVE PAYEES MUST SIGN FOR MINORS
AND FOR INCAPABLE OR INCOMPETENT ADULTS.
(Write in ink)

DATE

TELEPHONE NUMBER WHERE
YOU MAY BE CONTACTED
DURING THE DAY

a.

b.

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

ADDRESS (NUMBER AND STREET)

CITY

POSTAL CODE

ADDRESS (NUMBER AND STREET)

COUNTRY

CITY

POSTAL CODE COUNTRY

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PRIVACY ACT STATEMENT

See Revised Privacy Act
Statement Attached

Section 202 of the Social Security Act, as amended, and 871 and 1441 of the Internal Revenue Code,
allow us to collect this information. We will use the information you provide to determine eligibility for
payments of benefits and to determine tax-withholding status.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent us from making an accurate and timely decision on any claim filed, or could result in the loss
of benefits.
We rarely use the information you supply for any purpose other than what we state above, however, we
may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to
the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to private
entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0089, entitled Claims Folders Systems and 60-0090, entitled
Master Beneficiary Record. Additional information about these and other system of records notices and
our programs are available from our Internet website at www.socialsecurity.gov or at your local Social
Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.

PAPERWORK REDUCTION ACT STATEMENT - This information collection meets the requirements of
44 U.S.C. § 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 (OMB) control
number. The OMB number for this collection is 0960-0051. We estimate that it will take about 10 minutes
to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office
through SSA’s website www.socialsecurity.gov. Offices are also listed under U.S. Government agencies
in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.