Current SSA-21

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. )

Form Approved
OMB No. 0960-0051

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 Northern Mariana Islands, or American Samoa.
1. NAME OF WORKER ON WHOSE EARNINGS THIS CLAIM IS BASED
2. WORKER'S SOCIAL SECURITY NUMBER
3.

LIST BELOW THE FULL NAME OF THE
WORKER (EVEN IF DECEASED) AND OF EACH COUNTRY OF
BENEFICIARY IN THE SAME HOUSEHOLD
BIRTH
WHO IS, WAS OR WILL BE OUTSIDE THE
UNITED STATES.

COUNTRY WHERE YOU
LIVE
PRESENT

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

a.
b.
c.
d.
4.

Note: All persons listed above or their representative payees must sign the certification in item 18.
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, complete
item 4 by entering the name of the beneficiary and dates (month, day and year) he or she was or will be outside the U.S. NOTE: Entries
should not be made by residents of Canada or Mexico who are entering the U.S. on a daily basis to work or visit and returning each day to
their residence in Canada or Mexico.
OUTSIDE U.S.
OUTSIDE U.S.
DATE OF EXPECTED
NAME
RETURN TO U.S. (If within
FROM
TO
FROM
TO
the next 18 months)
Mo-Day -Yr
Mo-Day-Yr
Mo-Day-Yr
Mo-Day-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
DATE(S)
NAME

6.

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

No

Yes

No

DATE(S)

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(s) work is expected to begin.
NAME
DATE
NAME

7.

Yes

DATE

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

a.
b.
c.
d.
If you need more space, use "REMARKS" on page 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 or
aggravated in the military service?

9.

Supplementary Medical Insurance generally is payable only for medical services provided inside the United States. If any one 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.
NAME(S)

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

No

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 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 United States that do not permit the taxing of U.S. Social Security
benefits or 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

11.

PERMANENT RESIDENT CARD
(GREEN CARD) NUMBER

DATE CARD WAS ISSUED

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

NAME

DATE (MONTH AND
YEAR) NOTICE WAS
GIVEN TO DHS

Has any person listed in item 10 been notified by DHS that he or she no longer has U.S. resident status or has
his or her Permanent Resident Card been taken by DHS?
Yes
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.
DATE (MONTH AND
NAME
YEAR) NOTICE WAS
NAME
GIVEN TO DHS

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

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No

DATE (MONTH AND
YEAR) NOTICE WAS
GIVEN TO DHS

13.

Does each person listed in item 10 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.?

Yes

No

Yes

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

CITY

POSTAL CODE COUNTRY

a.
b.
c.
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.
Form SSA-21 (08-2012) ef (08-2012)

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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.
SIGNATURE (FIRST NAME, MIDDLE INITIAL, AND LAST NAME)
TELEPHONE NUMBER WHERE YOU
OF EACH PERSON LISTED IN ITEM 3. REPRESENTATIVE
DATE
PAYEES MUST SIGN FOR MINORS AND FOR INCAPABLE OR
MAY BE CONTACTED DURING THE DAY
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)

CITY

ADDRESS (NUMBER AND STREET)

POSTAL CODE COUNTRY

CITY

POSTAL CODE COUNTRY

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

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