Information Collection

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

IC 187515 under ICR 201608-0960-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-21 SSA-21 - U.S. Residents, Paper Version Form and Instruction
SSA-21 Supplement to Claim of person Outside the United States SSA-21 - Revised (Fillable).pdf Form and Instruction
SSA-21 - Current.pdf Current SSA-21 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-21 - U.S. Residents, 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 422.505(b) 20 CFR 404.460 42 CFR 407.27(c) 20 CFR 404.463

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	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 (Fillable).pdf		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: 3,669	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,669	3,669
Annual IC Time Burden (Hours)	917	917
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-21	SSA-21 - Current.pdf	09/20/2016

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