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

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 (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 lines (b) through (d) for each beneficiary in the same household who
is outside the U.S., has been outside the U.S. in the past 24 months, or expects to be outside the U. S. in the next 3 months. If you need
more space, use the ”REMARKS” section on page 3.
DATES OUTSIDE THE U.S.

FULL NAME
FROM
Mo-Day -Yr

TO
Mo-Day -Yr

COUNTRY
WHERE
LIVING

COUNTRY
OF BIRTH

PERSON HAS U.S.
COUNTRY(IES) OF IF
PASSPORT, LIST:
PRESENT
CITIZENSHIP
PASSPORT NO. DATE
ISSUED
(Or at time of death)

a.
b.
c.
d.
Note: All persons listed above or their representative payees must sign the certification in item 18.
4.

If any beneficiary listed in item 3 is not a U.S. citizen, complete line (a.) below for the worker (even if deceased). Complete the
information on lines (b) through (d), as needed, for each beneficiary in item 3 who is not a U.S. citizen. Do not include dates when
residents of Canada or Mexico are entering the United States on a daily basis to work or visit and returning each day to their
residence in Canada or Mexico. If you need more space, use the ”REMARKS” section on page 3.

FULL NAME

TOTAL
DATES LIVED IN THE U.S.
DATES LIVED IN THE U.S.
NUMBER OF FROM
RELATIONSHIP
RELATIONSHIP
TO
FROM
TO
TO WORKER
Mo-Day -Yr Mo-Day -Yr TO WORKER
YEARS Mo-Day -Yr Mo-Day -Yr
NAMED IN ITEM 1
NAMED IN ITEM
LIVED IN
DURING THIS
1 DURING THIS
THE U.S.
PERIOD
PERIOD

a.
b.
c.
d.
5.

6.

7.

8.

Has any person listed in item 3 been employed or self-employed outside the U.S. during any of the past12
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 3.
NAME
DATE(S) – (MO-YR) NAME

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 more space, use the
“REMARKS” section on page 3.
NAME
DATE – (MO-YR)
NAME



Yes



No

DATE(S) – ( MO-YR)



Yes



No

DATE – (MO-YR)

Answer item 7 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 or made
 Yes  No
worse while in military service?
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 3.
NAME(S)
IF EVERYONE LISTED IN ITEM 3 IS A U.S. CITIZEN, SKIP ITEMS 9 THROUGH 14 AND GO TO ITEM 15.
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Form SSA-21 (08-2012) ef (08-2012)
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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 U.S. 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. You must check with the Internal Revenue Service (IRS) for the most up-to-date list.
The IRS 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.
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 determined to
have been administratively or judicially abandoned, or
• Meets a substantial presence test as determined by the provisions of 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 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 days of U.S. presence and exclusions are defined in the IRC.
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 "REMARKS"
section on page 3.
PERMANENT RESIDENT CARD
NAME
DATE CARD WAS ISSUED
(GREEN CARD) NUMBER

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
( MONTH AND YEAR)

NAME

DATE
( MONTH AND YEAR)

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

DATE
(MONTH AND YEAR)

NAME

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 in the same way as the income of a person living in the U.S.? If no, enter the
name of each individual who does not understand in "REMARKS" section on page 3.
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 understand in "REMARKS" section on page 3.
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Form SSA-21 (08-2012) ef (08-2012)

DATE
(MONTH AND YEAR)

Yes

No

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 below.
Tax Treaty Country of Residence
NAME

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 below and show names for each address.
NUMBER AND STREET

CITY

POSTAL CODE

COUNTRY

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 "REMARKS" section below.
NAME
NUMBER AND STREET
CITY
POSTAL CODE
COUNTRY

a.

b.

c.

d.

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.)

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Form SSA-21 (08-2012) ef (08-2012)

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 penalty 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
TELEPHONE NUMBER WHERE YOU MAY BE
LAST NAME) OF EACH PERSON LISTED IN ITEM
DATE
3. REPRESENTATIVE PAYEES MUST SIGN FOR
CONTACTED DURING THE DAY
MINORS AND FOR INCAPABLE OR
INCOMPETENT ADULTS. Write in ink.

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

POSTAL CODE COUNTRY

POSTAL CODE COUNTRY

PRIVACY ACT STATEMENT
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 at 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 1-800-3250778). Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
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Form SSA-21 (08-2012) ef (08-2012)