Supplement To Claim of Person Outside the United States

OMB 0960-0051

OMB 0960-0051

Claimants or beneficiaries, both United States (U.S.) citizens and aliens entitled to benefits, living outside the U.S. complete Form SSA-21 as a supplement to an application for benefits. SSA collects the information to determine eligibility for U.S. Social Security benefits for those months an alien beneficiary or claimant is outside the U.S., and to determine if tax withholding applies. In addition, SSA uses the information to: (1) allow beneficiaries or claimants to request a special payment exception in an SSA Restricted country; (2) terminate Supplemental Medical Insurance coverage for recipients who request it, because they are, or will be, out of the U.S.; and (3) allow claimants to collect a lump sum death benefit if the number holder died outside the U.S. and we do not have information to determine the whether the lump sum death is payable under the Social Security Act. The respondents are Social Security claimants, or individuals entitled to Social Security benefits, who are, will be, or have been residing outside the U.S. for three months or longer.

The latest form for Supplement To Claim of Person Outside the United States expires 2021-05-31 and can be found here.

All Historical Document Collections
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Revision of a currently approved collection 2021-05-06
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Revision of a currently approved collection 2017-11-28
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No material or nonsubstantive change to a currently approved collection 2016-11-07
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No material or nonsubstantive change to a currently approved collection 2015-12-30
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Revision of a currently approved collection 2014-12-01
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No material or nonsubstantive change to a currently approved collection 2012-06-01
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Revision of a currently approved collection 2012-01-26
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Extension without change of a currently approved collection 2009-02-05
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Revision of a currently approved collection 2005-12-21
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Extension without change of a currently approved collection 2003-07-03
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Extension without change of a currently approved collection 2000-07-03
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Extension without change of a currently approved collection 1997-06-23
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Extension without change of a currently approved collection 1994-04-08
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Extension without change of a currently approved collection 1991-02-07
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Extension without change of a currently approved collection 1988-03-07
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Revision of a currently approved collection 1985-04-24
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Revision of a currently approved collection 1984-01-23
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Revision of a currently approved collection 1982-02-18
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Revision of a currently approved collection 1978-03-14
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Extension without change of a currently approved collection 1976-03-04
OMB Details

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

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-21Supplement to Claim of Person Outside the United StatesFillable PrintableForm and instruction

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