Information Collection

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

IC 212848 under ICR 202103-0960-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0051 Privacy Act Statement (revised).docx	Other-Revised PA Statement
0051 PRA Statement (revised).docx	Other-Paper Reduction Act 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	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			0051 Privacy Act Statement (revised).docx	Yes	No	Fillable Printable
Other-Paper Reduction Act Statement revised			0051 PRA Statement (revised).docx	No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,379

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,379	-456	1,835
Annual IC Time Burden (Hours)	184	-61	245
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	04/28/2021

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