Supporting Statement - 0960-0051 (final)

Supporting Statement for SSA-21

Supplement to Claim of Person Outside the U.S.

20 CFR 422.505(b), 404.460, 404.463, and 42 CFR 407.27(c)

OMB No. 0960-0051

A. Justification

1. Introduction/Authoring Laws and Regulations

In accordance with Section 20 CFR 422.505(b) of the Code of Federal Regulations (Code), Form SSA-21 is used with applications for retirement, survivors, and disability insurance benefits. The Social Security Administration (SSA) collects information as evidence to establish the right to benefits under the authority of section 205 of the Social Security Act (Act). We use Form SSA-21 to collect information about the citizenship and residency of claimants and beneficiaries who are, have been, or will be outside the United States (U.S.). SSA uses the citizenship and residency information we collect from a claimant or beneficiary who is not a U.S. citizen (alien) to determine if the individual is subject to the alien nonpayment provision under section 202(t) of the Act; as well as under 20 CFR 404.460, and 20 CFR 404.463 of the Code. Section 202(t)(1) of the Act and 20 CFR 404.460 of the Code prohibit the payment of monthly benefits to aliens who were outside the U.S. for six consecutive calendar months. SSA does not resume payments suspended under this provision until the alien remains present in the U.S. for an entire calendar month. Section 26 CFR 1.1441-1(e)(4)(vi ) allows SSA to use Form SSA-21 as an acceptable substitute for IRS form W-8BEN.

Section 202(t) of the Act, and sections 20 CFR 404.460 and 20 CFR 404.463 Subpart E of the Code also provide exceptions to the alien nonpayment provision (ANP) in section 202(t)(1) of the Act. The information we collect on Form SSA‑21 helps to determine if certain exceptions apply to the claimant or beneficiary completing the form.

Section 202(t)(11) of the Act requires certain alien dependent or survivor claimants, or beneficiaries, subject to the ANP, to meet an additional 5-year residency requirement. Form SSA-21 collects the information we use to determine if these dependent or survivor claimants or beneficiaries have enough U.S. residency to meet the 5-year residency requirement.

Section 1838(b) of the Act and 42 CFR 407.27(c) of the Code state individuals may give SSA written notice that they no longer wish to be enrolled for Supplementary Medical Insurance (SMI). Form SSA-21 informs claimants and beneficiaries who are required to complete the form that they can only use SMI benefits inside the U.S. Beneficiaries already enrolled in SMI who complete Form SSA-21 when they leave the U.S. may use this form to cancel their SMI coverage.

We collect information about work outside the U.S. to make the above-mentioned determinations under the authority of Section 203 of the Act. We require information about citizenship, residency and alien status to determine whether we must withhold nonresident alien tax as required under section 121 of Public Law 98‑21, and sections 1441 and 871(a)(3) of the Internal Revenue Code (IRC).

2. Description of Collection

Claimants or beneficiaries (both 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. Claimants or beneficiaries know to complete the SSA-21 through one of the following methods: 1) SSA sends a letter or notice explaining the need to complete the SSA-21 form and includes instructions on how and when to complete it; 2) SSA representatives inform respondents during phone calls, in-person interviews, or other contacts that they need to complete the SSA-21 form as part of their case or benefits review; 3) caseworkers, legal representatives, or authorized representatives advise respondents to complete the SSA-21; or 3) SSA provides instructions via mail or online portals directing respondents to complete and return the SSA-21.

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 SMI coverage for recipients who request it, because they are, or will be, outside 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 whether the lump sum death benefit is payable under the Social Security Act. SSA technicians collect information from Form SSA-21 in the following three circumstances:

1. When a non-U.S. citizen claimant files an initial or subsequent claim and meets all of the following conditions:

• Has been, or expects to be, outside the U.S. for 30 consecutive days or more during the period beginning six months before the elected date of entitlement, and ending six months after the date of application; and

• Is not requesting a special payment exception while in an SSA Restricted Country.

2. All claimants, including a U.S. citizen, who request a special payment exception in an SSA restricted country.

3. A claimant who files for the lump-sum death payment (LSDP) on the record of a number holder (NH) who died while residing outside of the U.S. and there is no information to show whether the NH met an exception to the ANP.

SSA offers two alternative mechanisms for collecting information from Form SSA-21: SSA’s Internet Claims (iClaim) application automatically collects information from Form SSA-21. In addition, technicians may propagate macros into the remarks screen of the Modernized Claims System (MCS) when processing applications during a phone interview or a mailed form to capture information from the SSA-21.

SSA processes the information from Form SSA-21 based on the situation in question. When a claimant or beneficiary meets the criteria outlined in 1-3 above, SSA must secure Form SSA-21 to determine what action, if any, is necessary.

In post-entitlement situations, the information on Form SSA-21 may be used to process:

• change of address;

• change in citizenship;

• special payment exception for beneficiaries living in an SSA restricted country;

• suspension of benefits due to employment or self-employment outside of the U.S.;

• termination of SMI Part B; and

• resumption of benefits after suspension for unlawful presence in the U.S.

We identified the following psychological costs based on the requirements for this information collection:

• Psychological Cost #1:

  • Requirement for the Program: Form SSA-21 asks individuals to provide extensive information about themselves and others so SSA can determine whether they can continue to receive benefits while living outside of the U.S.

• Psychological Cost: The respondent may perceive these questions as too cumbersome or invasive, and these factors can lead to individuals choosing to delay or abandon completing this form.

• Psychological Cost #2:

  • Requirement for the Program: Form SSA-21 asks individuals to supply any new evidence to SSA which supports their need for this benefit.
    
    

  • Psychological Cost: The respondent might perceive that the agency distrusts them and their claim for benefits. Because of this, some may find the entire process stressful to the point that it may take them longer to complete the application, or they may postpone it, or stop answering the questions entirely.

We understand these psychological costs may cause respondents to delay their completion of the information collection or cause them to abandon the information collection entirely. However, we require full completion of this collection to continue to receive benefits. Therefore, we have taken this potential psychological cost into account when calculating our burden in #12 below.

The respondents are Social Security claimants, or individuals entitled to Social Security benefits, who are, were, or will be residing outside the U.S. for three months or longer.

2. Use of Information Technology to Collect the Information

SSA no longer stocks Form SSA-21 in paper form, rather it is available in PDF fillable format on SSA’s website, and our internal website. SSA no longer requires claimants using the Internet, iClaim application to complete a paper form SSA-21; rather the agency collects the information directly through iClaim. A claimant or beneficiary may complete the Form SSA-21 using the fillable PDF, and print it for submission, or they can complete it manually after printing it; sign it; and deliver the completed SSA-21 to a Social Security office either by mail or in person. SSA also accepts signature proxy through attestation when completed through a personal interview with an SSA representative in person or by phone. For telephone interviews, we accept completion of the standardized text (Form SSA-21 macros added to the MCS application) in lieu of the paper form.

This collection also has a public-facing fillable and submittable version which the respondent can complete and submit using SSA’s Upload Documents Portal (OMB No. 0960‑0830). Upload Documents allows the respondent to complete the fillable PDF, electronically sign it, and submit the information through the Upload Documents Portal. The submittable version mirrors the paper version and provides respondents with an online service option as an alternative to mailing, faxing, or bringing the form to an SSA field office. Use of the Upload Documents Portal does not require respondents to download and install the application locally on their device or pay any subscription or licensing fees, and we account for the burden for using Upload Documents under OMB No.

0960-0830.

2. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

Form SSA-21 collects the specific citizenship and residency information SSA needs to determine nonresident alien withholding status and the applicability of the ANP. If SSA did not collect this information, we risk overpayment of benefits to aliens who remain outside the U.S. for more than six consecutive calendar months. We also risk not meeting our obligation to withhold nonresident alien tax when applicable. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on April 4, 2025, at

90 FR 14891, and we received no public comments. The 30-day FRN published on June 17, 2025, at 90 FR 25734. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

8. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

8. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

8. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

8. Estimates of Public Reporting Burden

Modality of Collection	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Average Wait Time in Field Office or for Teleservice Centers (minutes) **	Total Annual Opportunity Cost (dollars)***
Paper version - U.S. Residents	143	1	14	33	$22.98*	23*	$2,022***
Paper version - Residents of a Tax Treaty Country	755	1	9	113	$22.98*		$2,597***
Paper version -Nonresident aliens	570	1	8	76	$22.98*		$1,746***
Intranet version -(MCS) - U.S. Residents	371	1	11	68	$22.98*	180**	$27,159***
Intranet version -(MCS) - Residents of a Tax Treaty Country	1,956	1	6	196	$22.98*	180**	$139,351***
Intranet version -(MCS) - Nonresident aliens	1,485	1	5	124	$22.98*	180**	$105,225***
Totals	5,280			610			$278,100***

* We based this figure on average DI payments (https://www.ssa.gov/legislation/2024FactSheet.pdf) and the average U.S. worker’s salary; as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics).

** We based this figure on the average FY 2025 wait times for field offices (23 minutes) and telephone centers (180 minutes), based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete.

In addition, OMB’s Office of Information and Regulatory Affairs is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97-mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)****
143	1	30	72	$1,612

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data, which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total opportunity cost estimates in the paragraph below.

We calculated the following Learning Cost time burden based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument):

Total Number of Respondents	Frequency of Response	Estimate Learning Cost (minutes)	Estimated Total Annual Burden (hours)	Total Annual Learning Cost (dollars)*****
5,280	1	10	880	$20,222*****

*****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that 10 minutes accurately shows the average burden per response for learning about the program; receiving notices as needed; reading and understanding instructions; gathering the data and documents needed; answering the questions and completing the information collection instrument; scheduling any necessary appointment or required phone call; consulting with any third parties (as needed); and waiting to speak with SSA employees (as needed). Based on our current management information data, the current burden information we provided is accurate. The total burden for this ICR is 610 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $299,934. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $87,140. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$0*
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$86,240
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$900
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$87,140

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have. Additionally, it is difficult for us to break down the cost for processing a single form, as field office, program service center staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent. As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

When we last cleared this IC in 2021, the burden was 1,030 hours. However, we are currently reporting a burden of 610 hours. This change stems a decrease in the number of respondents completing Form SSA-21, and, therefore, a decrease in the number of responses from 8,275 to 5,280. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

* Note: The total burden reflected in ROCIS is 13,053, while the burden cited in #12 of the Supporting Statement is 610 . This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + telephone waiting time + a rough estimate of a 30-minute, one-way, drive burden + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper form SSA-21, we will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

For the Internet version of form SSA-21 (through iClaim), SSA is not requesting an exception to the requirement to display the OMB approval expiration date .

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at

5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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