Information Collection

SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), Paper Version

IC 212848 under ICR 201707-0960-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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 - Non-Resident Alien (not a resident of a tax treaty country), Paper Version	Form and Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-21 Supplement to Claim of Person Outside the United States SSA-21 - Revised.pdf	Form and Instruction
SSA-21 - Current.pdf Current SSA-21	IC Document

IC Title:

SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), 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 404.460 20 CFR 404.463 20 CFR 422.505(b) 42 CFR 407.27(c)

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.pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,835

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,835	-722	2,557
Annual IC Time Burden (Hours)	245	-181	426
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-21	SSA-21 - Current.pdf	10/24/2017

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