Information Collection

SSA-21 - U.S. Residents, Paper Version

IC 187515 under ICR 201511-0960-001 · OMB 0960-0051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0051 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-21 SSA-21 - U.S. Residents, Paper Version	Form and Instruction
SSA-21 Supplement to Claim of person Outside the United States SSA-21 Revised Version 10-2015.pdf	Form and Instruction
SSA-21 Current Version.pdf Current SSA-21	IC Document

IC Title:

SSA-21 - U.S. Residents, Paper Version

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 422.505(b) 20 CFR 404.460 42 CFR 407.27(c) 20 CFR 404.463

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-21	Supplement to Claim of person Outside the United States	SSA-21 Revised Version 10-2015.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,669

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,669	3,669
Annual IC Time Burden (Hours)	917	917
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-21	SSA-21 Current Version.pdf	11/02/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.