Form SSA-21 – Fill Out and Use This PDF

Form SSA-21 (05-2018) UF
Discontinue Prior Editions	Page 1 of 5
Social Security Administration	OMB No. 0960-0051

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

b.

c.

d.

FOR EACH WORKER LISTED ABOVE, CONTINUE TO LIST INFORMATION REQUESTED BELOW:

		COUNTRY		DATES OUTSIDE THE U.S.
	WORKER/PERSON LISTED ABOVE		FROM		TO	COUNTRY WHERE
		OF BIRTH
			Mo-Day-Yr		Mo-Day-Yr	LIVING
	WORKER LISTED ABOVE IN ROW (a.)
	PERSON LISTED ABOVE IN ROW (b.)
	PERSON LISTED ABOVE IN ROW (c.)
	PERSON LISTED ABOVE IN ROW (d.)

NOTE: ALL PERSONS LISTED ABOVE AND IN THE "REMARKS" SECTION ON PAGE 4, OR THEIR REPRESENTATIVE PAYEES, MUST SIGN THE CERTIFICATION IN ITEM 18.

4.Complete line (a) for the worker (even if deceased). Complete (b) through (d) for each claimant or beneficiary listed in item 3 who is not a U.S. citizen. Do not include the days that residents of Canada or Mexico enter the U.S. on a daily basis to work or visit and return each day to their residence in Canada or Mexico, as dates lived in the U.S. If you need more space, use the “REMARKS” section on page 4.

			TOTAL			DATES LIVED IN THE U.S.
	FULL NAME		NUMBER OF						RELATIONSHIP TO
			YEARS		FROM	TO
			LIVED IN		Mo-Day-Yr	Mo-Day-Yr	WORKER NAMED IN ITEM 1
			THE U.S.					DURING THIS PERIOD
	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(s) and date(s) work began and submit Form								YES		NO
	SSA-7163 (available at www.socialsecurity.gov). If you need more space, use the
	"REMARKS" section on page 4.
	NAME	Date (Mo - Yr)			NAME						Date (Mo - Yr)

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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(s) and date(s) work is expected to begin. If you need			YES	NO
	more space, use the “REMARKS” section on page 4.
	NAME	Date (Mo - Yr)	NAME		Date (Mo - Yr)
7.	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 worse while in			YES	NO
	military service?

8.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 4.

NAME(S)

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 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. For details and changes regarding income tax treaties, you may check with the Internal Revenue Service.

For Federal income tax purposes, a person can be considered a U.S. resident, even if that person lives outside the United States, if he or she:

•Has not claimed a tax treaty benefit as a resident of a country other than the United States in the same year; AND

•Has been lawfully admitted to the United States 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 defined by 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 the 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 IRC defines days of U.S. presence and exclusions for applying the substantial presence test.)

If you are a U.S. resident alien for Federal income tax purposes, generally your worldwide income is subject to U.S. income tax, regardless of where you are living.

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.

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 (Mo-Yr)	NAME	Date (Mo-Yr)

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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 regardless of where he or she is living? If no, enter the name	YES	NO
	of each individual who does not understand in the "REMARKS" section on page 4.
	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	YES	NO
	provisions of a tax treaty between the U.S. and the foreign country? If no, enter the name of each
	individual who does not agree in the "REMARKS" section on page 4.

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 on page 4.

		TAX TREATY COUNTRY	DATES OF RESIDENCE
	NAME	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 on page 4 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 the "REMARKS" section on page 4.

NAME	NUMBER AND STREET	CITY	POSTAL CODE	COUNTRY

a.

b.

c.

d.

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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.)

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 penalties 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.

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)