Currently Approved SSA-21

___________________________________________________________________________________________________________
IF EVERYONE LISTED IN ITEM 3 IS 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 30 percent Federal income tax
from the taxable benefits paid to beneficiaries who are neither citizens nor residents of the United States unless exempt (or subject to a
lower rate) by tax treaty. Currently, 85 percent of retirement, survivors and disability social security monthly benefits are considered
taxable benefits.
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Has been lawfully admitted to the U.S. for permanent residence and that residence has not been revoked or administratively or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.
PERMANENT RESIDENT CARD
NAME
(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?

Yes

No

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

NAME

12.

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

NAME

Has any person listed in item 10 been notified by DHS/INS that he or she no longer has U.S. resident
status or has his or her Permanent Resident Card been taken by DHS/INS?
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 DHS/INS.
DATE (MONTH AND
YEAR) OF NOTICE OR
NAME
NAME
DATE DHS/INS TOOK
THE CARD

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

Page2

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

Yes

No

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

See Revised Privacy Act
Statement

See Revised Privacy Act Statement

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 control number for this
collection is 0960-0051. We estimate that it will take between 10 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
(SSA-21)

Section 202 of the Social Security Act, as amended, and sections 871 and 1441 of the Internal
Revenue Code, authorizes us to collect and verify this information. We will use the information
you provide to determine eligibility for our programs.
Furnishing us this information is voluntary. However, failure to provide all or part of the
information could prevent us from making an accurate and timely decision on your eligibility to
our programs.
We rarely use the information you supply for any purpose other than for making a determination
relating to our benefits. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information are available in Systems of Records Notices
entitled, Claims Folders System, 60-0089, and Master Beneficiary Record, 60-0090. These
notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.