Addendum to the Supporting Statement for 0960-0051

Addendum to the Supporting Statement for Form SSA-21

Supplement to Claim of Person Outside the United States

20 CFR 422.505(b), 20 CFR 404.460, 20 CFR 404.463, 42 CFR 407.27(c)

OMB No. 0960-0051

Revisions to the Collection Instrument:

• Change #1: We added “for 30 consecutive days or more” to the definition of the “outside the United States” and defined the abbreviation for “United States” as “U.S.”

Justification #1: We changed the definition of “outside the United States” to match the definition in 20 CFR 404.460 and we defined the abbreviation for United States so we can use it throughout the form.

• Change #2: We changed the instructions for completing item 3, moved the “Dates Outside the U.S.” from the former item 4, and bolded the “NOTE” in item 3.

Justification #2: We made these changes to make this item easier to understand and clarify the information we are seeking.

• Change #3: We combined items 4 and 7 into the new question – item 4, changed the instructions, and moved “Dates Outside the U.S.” (formerly in item 7) to item 3. As a result, item 8 becomes the new item 7, item 9 becomes the new item 8, number 10 becomes the new item 9, number 11 becomes the new item 10, number 12 becomes the new number 11, number 13 becomes the new item 12, and item 14 becomes the new item 13. We added a new item 14.

Justification #3: We combined item 4 and 7 to make space on the form to add a new item 14 and to reduce the burden to the respondents. Our revisions to the instructions made them clearer and more specific. We explain the new item 14 in Change #13 (see below).

• Change #4: We changed item 5 to include a request to submit Form SSA-7163, and instructions for where to locate the form, if foreign work applies. We added “MO-YR” to the box labeled “DATES(S)” and added instructions if the respondent needs additional space.

Justification #4: We instructed the respondent to obtain and submit Form SSA-7163, if applicable, to expedite the claims process and reduce the need for re-contact. We added the label to the date to specify that we need the month and year. We provided the same instructions about additional space consistently throughout the form.

• Change #5: We added “MO-YR” to the box labeled “DATES” and added instructions to use the “REMARKS” section if the respondent needs additional space.

Justification #5: We added the label to the date to specify that we need the month and year. We provided the same instructions about additional space consistently throughout the form.

• Change #6: We replaced the words “aggravated in the military service” with “made worse while in the military service” in new item 7 (formerly item 8).

Justification #6: We made this change to comply with plain language standards.

• Change #7: We added instructions in item 8 (formerly item 9) to use the “REMARKS” section if the respondent needs additional space.

Justification #7: We provided the same instructions about additional space consistently throughout the form.

• Change #8: We made changes to the language in the explanation at the top of page 2 before item 9 (formerly item 10).

Justification #8: We added a list of the tax treaty countries which allow reduction of nonresident alien tax on social security benefits to give respondents better information prior to answering the new item 14. We also provided a better explanation of the substantial presence test.

• Change #9: We eliminated the question about whether any person meets the conditions explained in item 10 (formerly item 11) and ask directly for the name of anyone who meets the conditions specified in this item. We replaced “DHS” and “INS” with “U.S. government” and incorporated the following language recommended by IRS: “…or has commenced to be treated as a resident of a foreign country under the provisions of a tax treaty between the United States and the foreign country.”

Justification #9: We added the language recommended by IRS to qualify the SSA-21 as an acceptable substitute form for IRS form W-8BEN according to 26 CFR 1.1441-1(e)(4)(vi). We changed “DHS” and “INS” to “U.S. government” for consistency with the language in IRS publications and forms. Finally, by eliminating the “yes” or “no” question, we made room on the form and alleviated burden to the respondent.

• Change #10: We eliminated the question about whether any person meets the conditions explained in item 11 (formerly item 12) and ask directly for the name of anyone who meets the conditions specified in this item. We replaced “DHS” and “INS” with “U.S. government.”

Justification #10: We changed “DHS” and “INS” to “U.S. government” for consistency with the language in IRS publications and forms. By eliminating the “yes” or “no” question, we made room on the form and alleviated burden to the respondent.

• Change #11: In item 12 (formerly item 13), we changed the reference from “item 10” to “item 9” and changed the reference from “REMARKS” below” to “REMARKS section on page 3.”

Justification #11: We made these changes to make the reference valid with the other revisions on this form and to be consistent about providing instructions for additional space needed.

• Change #12: We added language in item 13 (formerly item 14) as recommended by IRS. We also changed the reference from “item 10” to “item 9” and changed the reference to “REMARKS below” to “REMARKS section on page 3.”

Justification #12: We added the language recommended by IRS to qualify the SSA-21 as an acceptable substitute form for IRS form W-8BEN according to 26 CFR 1.1441-1(e)(4)(vi). The changes to the two references (item 9 and “REMARKS” section on page 3) were necessary to make the references valid with the other revisions on this form.

• Change #13: We added the new question in item 14 as recommended by IRS.

Justification #13: We added the language recommended by IRS to qualify the SSA-21 as an acceptable substitute form for IRS form W-8BEN according to 26 CFR 1.1441-1(e)(4)(vi).

• Change #14: We changed “REMARKS above” to “REMARKS section below” in item 15.

Justification #14: This change was necessary to make the reference valid with the other revisions on this form.

• Change #15: We changed “REMARKS above” to “REMARKS section below” in item 16.

Justification #15: This change was necessary to make the reference valid with the other revisions on this form.

• Change #16: We moved the “REMARKS” section after item 17.

Justification #16: We moved this section so that it comes after all items for which respondents may use REMARKS. Previously the “REMARKS” section was before item 15 but items 15 through 17 referred respondents to REMARKS if needed, and we wanted to ensure consistency of language throughout the form.

• Change #17: We changed the Penalty of Perjury Statement as recommended by IRS.

Justification #17: We changed the language as recommended by IRS to qualify the SSA-21 as an acceptable substitute form for IRS form W-8BEN according to 26 CFR 1.1441‑1(e)(4)(vi).

• Change #18: We revised the Privacy Act Statement.

Justification #18: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement of the form.

• Change #19: We revised the Paperwork Reduction Act Statement (PRA).

• Justification #19: We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #20: We are asking for approval of an electronic version of this IC in the form of MCS Macros. We are submitting a copy of the MCS Macros and the script that is to be read when taking the claim in MCS. We are asking OMB to approve the Macros, used in conjunction with reading of the script, for use in lieu of form SSA-21when taking a claim (by phone or in-person interview) directly into MCS.

Justification #20: By reading the script to the claimant, the interviewer will provide the information from the SSA-21 the respondent needs to give accurate and informed answers to the questions in the Macros, and provide the statements to which the respondent agrees when signing the application. SSA representatives who complete the MCS claim will use the Macros whenever the conditions require they ask questions from the SSA-21. The Macros eliminate duplicate information because they only include questions from Form SSA-21 that we do not already request through the other screens in the MCS application.

We are including new and old versions of Form SSA-21 with this ICR submission. The new version has changes highlighted in yellow (the highlighting is for demonstration purposes and is not meant to printed or become a permanent part of the form). We will make all the highlighted revisions upon OMB’s approval of the changes listed above. In addition, we will institute the new MCS Macros upon OMB’s approval of this information collection request.