SSA-21 - U.S. Residents, Paper Version

Supplement To Claim of Person Outside the United States

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0051 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-21 SSA-21 - U.S. Residents, Paper Version Form and Instruction
Revised PA Statement.pdf Other-Revised PA Statement
SSA-21 Supplement to Claim of person Outside the United States SSA-21 - Revised.pdf Form and Instruction
SSA-21 - Current.pdf Current SSA-21 IC Document

Information Collection (IC) Details

IC Title:	SSA-21 - U.S. Residents, Paper Version	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407.27(c) 20 CFR 404.463 20 CFR 422.505(b) 20 CFR 404.460

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-21	Supplement to Claim of person Outside the United States	SSA-21 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 510	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	510	-3,159	3,669
Annual IC Time Burden (Hours)	119	-798	917
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-21	SSA-21 - Current.pdf	10/24/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.