Form Ssa 21 PDF Details

Form Ssa 21 is a form that is used to request disability benefits from the Social Security Administration. This form can be used to request benefits for yourself or someone else. The Social Security Administration reviews all requests for disability benefits and makes a determination on whether or not the person meets the criteria for eligibility. Depending on the situation, there may be other forms that need to be completed in addition to Form Ssa 21. It is important to understand the process and what is required so that you can submit a complete and accurate application.

QuestionAnswer
Form NameForm Ssa 21
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other names21 form print, ssa form 21, ssa form ssa 21, ssa 21

Form Preview Example

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

3.

Complete line (a) below for the worker (even if deceased). Complete (b) through (d) for each claimant or beneficiary who is not a U.S. citizen, and is outside the U.S., has been outside the U.S. in the past 24 months, or expects to be outside the U.S. for 30 consecutive days or more. Enter only the claimants or beneficiaries living in the same household. Complete a separate form for each household. If you need more space, use the “REMARKS” section on page 4.

FULL NAME

COUNTRY(IES) OF PRESENT

PASSPORT NO.

DATE ISSUED

CITIZENSHIP (Or at time of death)

 

 

 

a.

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)

 

 

 

 

 

 

 

 

 

 

 

 

Form SSA-21 (05-2018) UF

 

 

 

Page 2 of 5

 

 

 

 

 

 

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.

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 the "REMARKS" section on page 4.

NAME

PERMANENT RESIDENT CARD

DATE CARD WAS

(GREEN CARD) NUMBER

ISSUED

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form SSA-21 (05-2018) UF

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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 (Mo-Yr)

NAME

Date (Mo-Yr)

 

 

 

 

 

 

 

 

 

 

 

 

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.

Form SSA-21 (05-2018) UF

Page 4 of 5

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.

18.

SIGNATURE (FIRST NAME, MIDDLE INITIAL, AND LAST NAME) OF EACH PERSON LISTED IN ITEM 3.

REPRESENTATIVE PAYEES MUST SIGN FOR MINORS AND FOR INCAPABLE OR INCOMPETENT ADULTS.

(Write in ink)

DATE

TELEPHONE NUMBER WHERE

YOU MAY BE CONTACTED

DURING THE DAY

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

POSTAL CODE

COUNTRY

CITY

POSTAL CODE COUNTRY

Form SSA-21 (05-2018) UF

Page 5 of 5

 

 

PRIVACY ACT STATEMENT

Sections 202(t), 203, 205, and 1838(b) of the Social Security Act and sections 871(a)(3) and 1441 of the Internal Revenue Code, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide 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 will use the information to determine eligibility for benefits. We also use the form to determine nonresident alien tax withholding status. We may also share your information for the following purposes, called routine uses:

1.To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs. we will disclose information under this routine use only in situations in which SSA may enter into an contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records; and

2.To the Centers for Medicare and Medicaid Services, for the purpose of administering Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part D, including but not limited to: Medicare Part C enrollment and premium collection processes; Part D enrollment and premium collection processes; Medicare Part B premium reduction based on participation in a Part C plan and Medicare Part B enrollment and income-related monthly adjustment amount determinations, appeals of determinations, and premium collection.

In addition, we may share this IN FO RM AT IO N in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verity a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)

60-0089, entitled Claims Folders Systems, 60-0090, entitled Master Beneficiary Record, and 60-0321, entitled Medicare Database. Additional information and full listing of all our SORNs are available on our website at www.ssa.gov/privacy/sorn.html.

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 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 1-800-325-0778).

Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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1. Whenever completing the form 21, ensure to include all needed fields in its associated area. This will help facilitate the process, making it possible for your information to be handled efficiently and accurately.

Step # 1 in filling in ssa 21

2. Once your current task is complete, take the next step – fill out all of these fields - YEARS LIVED IN THE US, DURING THIS PERIOD, d Has any person listed in item, Date Mo Yr, NAME, YES, and Date Mo Yr with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step # 2 for submitting ssa 21

3. This next part is mostly about Does any person listed in item, Date Mo Yr, NAME, YES, Date Mo Yr, Answer item only if the worker, YES, Supplementary Medical Insurance, item is now enrolled in, NAMES, The US Internal Revenue Code IRC, Has not claimed a tax treaty, or determined to have been, and Meets a substantial presence test - type in each of these fields.

Part no. 3 of completing ssa 21

4. This specific subsection comes with the next few fields to type in your information in: NAME, GREEN CARD NUMBER, ISSUED, Enter the names of any persons, NAME, Date MoYr, NAME, and Date MoYr.

Step no. 4 for filling out ssa 21

5. This very last section to finish this PDF form is critical. You'll want to fill in the required blanks, which includes NAME, Date MoYr, NAME, Date MoYr, Does each person listed in item, YES, Does each person listed in item, residence status or if he or she, YES, INCOME TAX TREATY BENEFITS, income tax withholding under the, NAME, TAX TREATY COUNTRY, OF RESIDENCE, and DATES OF RESIDENCE, before finalizing. In any other case, it could end up in a flawed and potentially incorrect form!

Date MoYr, INCOME TAX TREATY BENEFITS, and Does each person listed in item in ssa 21

Always be very careful when filling out Date MoYr and INCOME TAX TREATY BENEFITS, as this is the section in which a lot of people make errors.

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