Information Collection

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

IC 187515 under ICR 202502-0960-012 · OMB 0960-0051.

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
Form SSA-21 Supplement to Claim of person Outside the United States SSA-21 - U.S. Residents, Paper Version	Form and Instruction
SSA-21 Supplement to Claim of person Outside the United States SSA-21 (revised).pdf	Form and Instruction
SSA-21 Supplement to Claim of person Outside the United States SSA-21 (revised).pdf	Form and Instruction
SSA-21 (current).pdf SSA-21 (current)	IC Document
SSA-21 (current).pdf SSA-21 (current)	IC Document

IC Title:

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 404.463 20 CFR 422.505(b) 20 CFR 404.460 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				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: 143

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	143	-217	360
Annual IC Time Burden (Hours)	184	100	84
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-21 (current)		06/04/2025

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

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