TN 48 (05-16)

Citations:

20 CFR § 422.505

A. Information about Form SSA-21

Form SSA-21 is listed in the Social Security Regulations, 20 CFR § 422.505 as a “related form” to use when applying for retirement, survivors, and disability insurance benefits.” This section describes when we require this form to be completed, how to complete the form, and how to use the information provided on the completed form.

For purposes of these instructions, the United States includes:

• the 50 States,

• the District of Columbia,

• Puerto Rico,

• the U.S. Virgin Islands,

• Guam,

• the Northern Mariana Islands, and

• American Samoa.

You can view an exhibit of Form SSA-21 in GN 00205.181. You can also find a copy of Form SSA-21 on SSA’s website at: http://www.socialsecurity.gov/online/ssa-21.pdf.

B. Purpose of Form SSA-21

The SSA-21 collects information that we use to make determinations under the following provisions:

• alien nonpayment provisions

• nonresident alien tax withholding provision

• lawful presence payment provision

In addition, we use the information collected on the SSA-21 to process the following actions:

• change of address

• change in citizenship

• special payment exception to beneficiaries in SSA restricted countries per RS 02650.040

• employment or self-employment outside the United States

• terminate Supplementary Medical Insurance (SMI) Medicare Part B

• resume benefits after suspension for unlawful presence in the United States

By signing Form SSA-21, claimants and beneficiaries (or their representative payees) agree to report events that might affect benefit payments or U.S. income tax withholding status.

When we request completion of the form in connection with an initial or subsequent claim, we accept a pen-and-ink (or “wet”) signature, click and sign (for iClaims applications), and form attestation. In post-entitlement situations, we accept “wet” signatures and form attestation. For more information about alternative signature methods, see GN 00201.015 and GN 00201.100.

C. When we require Form SSA-21 with an initial or subsequent claim

We require the following claimants to complete Form SSA-21 with an initial or subsequent claim:

1. Claimants who are not U.S. citizens, and

   • have been, or expect to be, outside the United States for 30 consecutive days or more during the period beginning 6 months before the elected date of entitlement, and ending 6 months after the date of application; and

   • who did not use the iClaim application after September 28, 2012 to apply for benefits.

NOTE: An SSA-21 is required with every request for special payment exception under the conditions in RS 02650.040, regardless of citizenship or method of application.

D. When we do not require Form SSA-21 with an initial or subsequent claim

We do not require claimants to complete Form SSA-21 with an initial or subsequent claim when the claimant meets any of the following conditions, unless he or she is requesting a special payment exception while in an SSA restricted country:

• claimant has not been, or does not expect to be, outside the United States for 30 consecutive days or more during the period beginning 6 months before the elected date of entitlement, and ending 6 months after the date of application

• claimant uses the iClaim application after September 28, 2012, to apply for benefits

• claimant is a U.S. citizen.

  NOTE: To be considered a U.S. citizen for this purpose, a claimant must have already established, or must currently establish, U.S. citizenship according to the guidelines in GN 00303.300 and GN 00303.320.

E. Examples of claims showing decisions about whether Form SSA-21 is required

1. Claimant is a not a U.S citizen

A number holder (NH) uses the iClaim application after September 28, 2012, to apply for retirement benefits. She is a citizen of Italy and had been in Italy for more than 30 consecutive days when she submitted her application.

Decision: We do not require Form SSA-21 from this claimant because the iClaim application will collect the same information as the SSA-21.

2. Claimants include a NH and children, all U.S. citizens born in the United States, and young wife who is a naturalized U.S. citizen

A NH applies for disability benefits at a border office near Canada. His wife and three children also apply for benefits on his record at the same time. Their residence address is in Canada and they have all been outside the United States for more than 30 consecutive days. The Numident records of the NH and his children show that they are U.S. citizens who were born in the United States. His wife’s Numident record confirms that she is a naturalized U.S. citizen.

Decision: We do not require Form SSA-21 from the NH, his wife, or his children, because our records confirm their U.S. citizenship.

3. Claimants include a widow, who is not a U.S. citizen, and her two children, who are U.S. citizens, all living in the same household

A widow applies for widow’s benefits for herself and child’s benefits for her two children on her deceased husband’s Social Security record while outside the United States. All claimants moved to the Dominican Republic two months after the NH’s death and reside in the same household. The widow is not a U.S. citizen but the Numident records of her two children confirm that they are U.S. citizens who were born in the United States.

Decision: The widow must complete Form SSA-21 because she is not a U.S. citizen. Although we do not need Form SSA-21 from the children, the widow will provide information about her children when she completes the form because the instructions say to provide information for “each beneficiary in the same household who is, was, or will be outside the United States.”

4. Claimants include a NH and spouse who are both U.S. citizens

A NH and aged spouse apply for benefits while living in the Ukraine, which is an SSA restricted country. Both claimants are U.S. citizens. They are requesting a special payment exception.

Decision: Although both claimants are U.S. citizens, they must complete an SSA-21 because they are requesting a special payment exception while in a restricted country per RS 02650.040.

F. When Form SSA-21 is required for a lump-sum death benefit claim

Obtain Form SSA-21 if the NH died outside the United States, and there is no information to show whether the NH met an exception to the alien nonpayment provisions. For more information about how the alien non-payment provision affects a lump-sum death benefit claim, see RS 02610.005B.1.

NOTE: A lump-sum benefit is not subject to nonresident alien tax because it is not a monthly benefit.

G. When we require Form SSA-21 for a post-entitlement case

Obtain Form SSA-21 for the following post-entitlement actions, regardless of the citizenship of the beneficiary, in the following circumstances:

• beneficiary has been, or expects to be, outside the United States for more than 3 months; or

• beneficiary is requesting a special payment exception while in an SSA restricted country under the conditions in RS 02650.040.

H. Retention of Form SSA-21

The retention period listed for the SSA-21, listed in the chart in GN 01085.025, is “UNTIL the paper claims file is destroyed”.

1. Retention of SSA-21 signed by signature proxy

When an SSA-21 is signed by signature proxy, follow the instructions in GN 00201.015F.6.

2. Retention rules when using click and sign for iClaims application version September 29, 2012, or later

The September 29, 2012, release of the iClaims application includes the questions from the SSA-21, collects the signature by “click and sign,” and propagates the information to the appropriate Modernized Claims System (MCS) screens. A copy of the Internet application summary is automatically updated to the Online Retrieval System (ORS).

3. Retention of a paper copy of Form SSA-21

SSA must retain the SSA-21 in the claims file. For information about storing documents and forms that cannot be stored or recorded in existing systems such as MCS or Evidence (EVID) screens, see GN 00301.316.

I. General information about completing and reviewing Form SSA-21 entries

Complete and review items on Form SSA-21 as follows:

• include information for each claimant or beneficiary who is required to complete an SSA-21 according to GN 00205.180C, GN 00205.180F, or GN 00205.180G in this section;

• obtain a separate SSA-21 from each family unit that contains a claimant or beneficiary who is required to complete the form;

• follow signature proxy procedures in GN 00201.015F.6., if applicable; and

• for information about completing the iClaim application, see GN 00204.055.

J. Itemized instructions for completing and reviewing items on Form SSA-21

1. Item 1 – Name of worker on whose earnings this claims is based

Enter name of the NH before giving it to the claimant or beneficiary (or representative payee).

2. Item 2 – Claim number

Enter the worker’s social security number before giving it to the claimant or beneficiary (or representative payee).

3. Item 3 – Residence and citizenship information

Enter information for each person who is required to complete an SSA-21 according to GN 00205.180F, or GN 00205.180G in this section. Each SSA-21 can only contain information about claimants and beneficiaries eligible for benefits based on one worker’s earnings who are living in the same household. Complete a separate SSA-21 for each separate household.

a. Full Name

Enter the full name of the NH (even if deceased) in the first column of line 3a on every completed SSA-21. Complete the remaining columns in line 3a with the NH’s information. Enter information in lines b. through d. for each claimant or beneficiary in one household who must complete an SSA-21.

b. Dates outside the U.S. column

For each person listed in the first column of item 3, enter the “FROM” and “TO” dates for the time the beneficiary has been, or expects to be, outside the United States and enter “COUNTRY WHERE LIVING” during that time.

Use alleged periods of absence from the United States to determine:

• status under the alien nonresident withholding tax provisions;

• whether payments can be made to non-U.S. citizens who do not meet an exception to the alien nonpayment provisions; and

• if we can resume payments to non-U.S. citizens going abroad who did not meet the lawful presence provisions while in the United States. (For details about resuming benefits under these circumstances, see RS 00204.055E.)

c. Country of birth column

Enter the country of birth for each individual named in the first column of the same line.

Use this information to evaluate allegations of citizenship using instructions in RS 02640.001 and RS 02640.010.

d. Country(ies) of present citizenship (or at time of death) column

Enter the citizenship of each individual named in the first column of the same line.

Use this information to determine citizenship status under the alien nonpayment and nonresident alien tax withholding provisions. Requirements for determining citizenship are located in RS 02640.000.

e. U.S. passport columns

If the beneficiary has a U.S. passport, enter the passport number and date issued.

Use this information to evaluate U.S. citizenship allegations using instructions in GN 00303.300E for an initial claim, and RS 02640.001 and RS 02640.010 for a postentitlement action.

4. Item 4 – Periods inside the United States

If any beneficiary in the household wishes to show that the NH lived in the United States for at least 10 years in order to qualify for the exception to the alien nonpayment provision explained in RS 02610.010B, enter the name of the NH in the first column of the first line and complete the Total Number of Years Lived in the U.S. and the Dates Lived in the U.S. columns.

For any beneficiary who wishes to show that he or she meets the 5 year residency requirement for payment under the alien nonpayment provisions in RS 02610.025, enter his or her name in the first column, and complete the remaining columns on that line.

Enter the name of any beneficiary who wishes to be considered a U.S. resident alien for U.S. income tax purposes under the substantial presence test, as described in GN 05010.010, in the first column and complete the remaining columns on that line.

5. Item 5 – Employment outside the United States in the past 12 months

Enter a mark in the “Yes” or “No” box to answer the question in item 5. If the answer is “Yes,” enter the name of the claimant or beneficiary in the box labeled “NAME” and the dates employed or self-employed in the box labeled “DATE(S).”

Use this information to decide whether the foreign work test applies per instructions in RS 02605.020.

6. Item 6 – Future employment outside the United States

Enter a mark in the “Yes” or “No” box to answer the question in item 6. If the answer is “Yes”, enter the name of the claimant or beneficiary in one of the boxes labeled “NAME”, and the date(s) the claimant or beneficiary expects to begin work in the box labeled “DATE” next to it.

Take action to diary the case to obtain a Form SSA-7163 (Questionnaire About Employment or Self-Employment Outside the United States) in the month the beneficiary expects employment or self-employment outside the United States to begin if:

• a claimant or beneficiary provides a date of future employment, and

• he or she will be under full retirement age when the employment is expected to begin.

7. Item 7 – Periods inside the United States

Answer Item 7 ONLY if the worker in item 1 is deceased. If the NH is deceased, enter a mark in the “Yes” or “No” box to answer the question in “item 8.”

Use this information to establish whether the deceased veteran exception to the alien nonpayment provisions applies. You will find more information about this exception in RS 02610.010B, 7^th bullet.

8. Item 8 – SMI termination

Enter the name of each individual who wishes to terminate his or her SMI enrollment. Take action to terminate SMI enrollment of each person listed in item 8 per HI 00820.045

9. Items 9 through 14 – Person is not a U.S. citizen

Read the information at the top of Form SSA-21, page 2, before completing items 9 through 14. Use the information entered in items 9 through 13 to decide if we can treat a claimant or beneficiary as a U.S. resident for tax purposes using instructions in GN 05010.030. Use the information in item 14 to qualify a claimant or beneficiary for a reduced rate of nonresident alien tax withholding due to an income tax treaty benefit.

• Item 9 – enter the name of any person listed in item 3 who is not a U.S. citizen, but can be considered a U.S. resident for tax purposes. If the claimant or beneficiary was admitted lawfully into the United States for permanent residence, enter the Permanent Residence Card number and date issued in the appropriate columns. A claimant or beneficiary who is a lawful permanent resident, must also complete items 10 and 11. Non-U.S. citizens shown in item 9, who are not admitted lawfully to the United States for permanent residence, can use the remarks portion of Form SSA-21 to explain why they consider themselves U.S. residents under the Substantial Presence Test. For information about the Substantial Presence Test, see GN 05010.040

• Item 12 and Item 13 – must be completed by every claimant or beneficiary listed in item 9 who has permanent resident status.

• Item 14 – this question must be completed by a claimant or beneficiary who meets the conditions of an income tax treaty that reduces federal income tax withholding from social security benefits, and wishes to claim the benefits of that treaty. The income tax treaties that provide some reduction of tax withholding are mentioned at the top the SSA-21, page 2, and can be found on IRS’s website at: www.irs.gov.

10. Item 15 – Payment Address

Complete this item if the claimant or beneficiary does not want payments sent directly to a bank or financial institution.

Take action to cancel any existing direct deposit arrangements for any beneficiary who completes this item, according to instructions in GN 02402.090. The following references pertain to foreign addresses:

• postal codes for certain foreign countries, see GN 02605.915;

• claimant requests a U.S. address in items 15 or 16, see GN 02401.080;

• foreign language equivalents of certain “post office box” address designations, see GN 00205.180K in this section; and

• foreign language equivalents of certain “in care of” address designations, see GN 02605.230C.

11. Item 16 – Mailing Address

Enter the full address where the claimant or beneficiary will receive mail while outside the United States, or enter “same as 15,” if it is identical to the address shown in “item 15.” If the mailing address is a post office box, the claimant or beneficiary must provide the residence address in Item 17. We list foreign language equivalents of the term “post office box” in GN 00205.180K of this section.

Use this information to update the address on the claim or Master Beneficiary Record (MBR).

12. Item 17 – Residence Address

Enter a residence address for each claimant or beneficiary shown in item 3. Show the full foreign residence address, unless it is the same as an entry in item 15 or 16, or the same entry as another claimant or beneficiary previously listed in item 17. If so, show “same as 15”, “same as 16”, or “same as 17 [letter of item],” as appropriate.

Use this information to annotate the full foreign residence address in the Special Message Data field on the MBR if it is different than the mailing address.

13. Item 18 – Signature of each person

All claimants or beneficiaries listed in item 3 (or their representative payee) must sign the SSA-21. A claimant or beneficiary who serves as the representative payee for others listed on the form need only sign once.

We do not require the NH to sign if he or she has not been, or does not expect to be, outside the United States.

Signature proxy instructions for Form SSA-21 in connection with a claim at the initial or appeals levels are located in GN 00201.015F.6, and for post-entitlement cases in GN 00201.100.

14. Item 19 – Signature of witnesses

We require the signature of two witnesses if any signature in item 18 was made by mark (X).

K. Foreign language equivalents of post office box

This is a list of foreign language equivalents of the term “post office box.” If the mailing address is a post office box, enter the residence address on Form SSA-21, Item 17. Add a special message on the MBR to document the full foreign address.

L. References

GN 00201.010 Signature Requirements

GN 00205.115 Retirement, Survivor, Disability Insurance (RSDI) Applications – Signature

GN 00301.286 Electronic Evidence Documentation and Retention

GN 01010.001 Adjudication Policy and Standards

GN 01010.100 Subsequent Title II Claims and Field Office (FO) Adjudication

GN 01085.001 Retention Periods for Program-Related Documents and Forms – Introduction

GN 01085.010 Essential Material Retained For Title II and Title XVI Claims

GN 01085.020 Retention Disposition Terms – Definitions

GN 01085.025 Exhibit – Retention Periods for Program-Related Forms

GN 01701.150 Alien Nonpayment Exemptions Under Totalization Agreements

GN 02605.200 Change of Address (COA) – Domestic to Foreign

GN 05010.000 Nonresident Alien Withholding Tax – Table of Contents

RS 00204.000 Lawful Presence Payment Provisions – Table of Contents

RS 02610.000 Alien Non-Payment Provisions – Table of Contents

SM 00510.075 Special Message (SP MSG 1) Data Line

SM 08001.001 What is the Claims File Records Management System (CFRMS)