SSA-21 Supplement to Claim of Person Outside the United States (Current Version)

Form Approved
OMB No. 0960-0051
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 Northem Mariana Islands, or American S amoa.
2. WORKER'S SOCIAL SECURITY NUMBER
1. NAME OF WORKER ON WHOSE EARNINGS THIS CLAIM IS BASED

-

LIST BELOW THE FULL NAME OF THE
WORKER (EVEN IF DECEASED) AND OF
EACH BENEFICIARY IN THE SAME

3.

COUNTRY
OF
BIRTH

HOU~I~~g~~ ~~I \~I~~~'?~~~kl BE

COUNTRY.~ERE

YOU I

PRESENT

OVER NEXT 12
MONTHS

-

COUNTRygES) OF
PRES NT
CITIZENSHIP
(Or at time of death)

IF PERSON HAS U.S.
PASSPORT LIST:
PASSPORT
NO.

DATE ISSUED

a.

b.

c.
d.
Note: All oersons listed above or their reQresentative payees must sign 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,
co~lete item 4 by enterin&:he 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
made by residents of Canada or Mexico who are entenng t e U.S. on a daily basis to work or visit and
retuming each day to their residence 10 Canada or Mexico.
DATE OF EXPECTED
OUTSIDE U.S.
OUTSIDE U.S.
RETURN TO U.S. (If within the
NAME
TO
FROM
FROM
TO
next 18 months)
Mo-Dav-Yr
Mo-Dav-Yr
Mo-Dav·Yr
Mo-Dav-Yr
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 and date(s) work began.
NAME

DNo

DATE(S)

NAME

DATE(S)

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 and date(~ work is ex~cted to begin.
iii'
NAME
NAME
DATE

I

7.

DYes

LIST BELOW THE NAME OF THE
WORKER AND OF EACH
BENEFICIARY LISTED IN ITEM 3

DYes

I

DNo

DATE

LIVING IN THE U.S.
NO. OF RELATIONSHIP TO
DATES PERSON LIVED IN THE U.S.
YRS. WORKER NAMED IN
LIVED ITEM 1 DURING THIS
FROM
TO
TO
FROM
IN U.S.
PERIOD
Mo-Day:Yr
Mo-Dav-Yr
Mo-D~Yr
Mo-D~Yr

a.

b.

c.
d.
If yoU need more space use "REMARKS" on paQ..e 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
Dyes
DNo
or aggravated in the military service?
9. Supplementary Medical Insurance generally is parrable only for medical services provided inside the United States. If anyone listed in
item 3 is now enrolled in Supplementary Medical nsurance under Medicare and wishes to terminate that enrollment, enter his or her
name here.
NAME(S)

...

Form SSA·21

(3-2006)

ef (3-2006)

..

Destroy pnor editions

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IF EVERYONE LISTED IN ITEM 31S A U.S. CITIZEN, SKIP ITEMS 10 THROUGH 14 AND GO TO ITEM 15.
The U.S. Internal 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 U.S., 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

o

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 DHSIINS

DATE (MONTH AND YEAR)
NOTICE WAS GIVEN TO
DHS/INS

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 DHS/INS?

...

DYes

ONo

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 (3-2oo6) ef (3-2006)

DATE (MONTH AND
YEAR) OF NOTICE OR
DATE DHS/INS TOOK
THE CARD

Page 2

NAME

DATE (MONTH AND YEAR) OF
NOTICE OR DATE DHS/INS
TOOK THE CARD

13. Does each person listed in item 10 understand that, as a U.S. resident, his or her wor1dwide income
will be subject to U.S. income tax in the same way as the income of a person living in the U.S.? - - .

0

Yes

0

No

0

Yes

0

No

If "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?
..
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 15" and go to item 17.)
NUMBER AND STREET

CITY

POSTAL CODE

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
COUNTRY
CITY
POSTAL CODE

a.
b.
v.

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.

Fonn SSA·21 (3-2006)

ef (3-2006)

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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.
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.

18.

SIGNATUREglRST NAME, MIDDLE INITIALtAND LAST
NAMEl F EACH PERSON LISTED IN I EM 3.
REPRESENT TIVE 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)

ADDRESS (NUMBER AND STREET)

CITY

CITY

IPOSTAL CODE/COUNTRY

I

I POSTAL CODE COUNTRY

PRIVACY ACT STATEMENT

The Social Security Administration is authorized to collect infonnation 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 infonnation 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 fonn is voluntary, failure to provide all or part of this
infonnation is cause for suspension of benefit payments. The infonnarion on this fonn may be disclosed by the Social Security Administration to
another person or agency for the following purposes: (I) 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 infonnation between the Social Security Administration and another agency.
We may also use the infonnation 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 aIlows us to do this even if you do not agree to it.
Explanations about these and other reasons why infonnation 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 infonnation col\ection 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 control number. We estimate that it wi1\ 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, J338 Annex
Building. Baltimore.MD 21235-6401. Send fl!1!J!. comments relating to our time estimate to this address, not the completed form.

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

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