Supplement To Claim of Person Outside the United States

Forms and Documents

Document Name	Status
Form SSA-21 SSA-21 - U.S. Citizen, Paper Version Form and Instruction	Modified
Form SSA-21 SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), Paper Version Form and Instruction	New
Form SSA-21 SSA-21 - Resident of Tax Treaty Country, Paper Version Form and Instruction	New
Form SSA-21 SSA-21 - U.S. Residents, Paper Version Form and Instruction	Modified
Addendum - 0051.docx Supplementary Document	2014-11-19
Supporting Statement - 0051.docx Supporting Statement A	2014-11-19

IC Document Collections

IC ID	Document Title	Status
8968	SSA-21 - U.S. Citizen, Paper Version Form and Instruction	Modified
212851	SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), MCS Macros Version Other-Internal Screens	New
212850	SSA-21 - Resident of a Tax Treaty Country, MCS Macros Version Other-Internal Screens	New
212849	SSA-21 - U.S Resident, MCS Macros Version Other-Internal Screens	New
212848	SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), Paper Version Form and Instruction	New
212847	SSA-21 - Resident of Tax Treaty Country, Paper Version Form and Instruction	New
187515	SSA-21 - U.S. Residents, Paper Version Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0051	ICR Reference No: 201408-0960-011
Status: Historical Active	Previous ICR Reference No: 201205-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Supplement To Claim of Person Outside the United States
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/06/2015
	Date Received in OIRA: 12/01/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved	02/28/2015
Responses	30,500	0	38,815
Time Burden (Hours)	4,933	0	3,558
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC 402.27 (c) Name of Law: Social Security Act
   PL: Pub.L. 98 - 21 121(c) Name of Law: Social Security Amendments of 1983
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 54341	09/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 68951	11/19/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
SSA-21 - Resident of a Tax Treaty Country, MCS Macros Version
SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), MCS Macros Version
SSA-21 - U.S. Citizen, Paper Version	SSA-21	Supplement to Claim of Person Outside the United States
SSA-21 - U.S. Residents, Paper Version	SSA-21	Supplement to Claim of person Outside the United States
SSA-21 - Non-Resident Alien (not a resident of a tax treaty country), Paper Version	SSA-21	Supplement to Claim of Person Outside the United States
SSA-21 - Resident of Tax Treaty Country, Paper Version	SSA-21	Supplement to Claim of Person Outside the United States
SSA-21 - U.S Resident, MCS Macros Version

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	30,500	38,815	0	20,024	-28,339	0
Annual Time Burden (Hours)	4,933	3,558	0	2,930	-1,555	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden decrease stems from our estimated use for the new MCS Macros version of this IC. Since we estimate it will take less time for respondents, we lowered the burden accordingly. In addition, we created individual listings for each type of respondent. As mentioned in #12 above, time estimates for completion differ dependent on modality as well as residency, and we also ask fewer questions dependent on citizenship status; therefore, to show the burden more accurately, we separated out the burden by respondent type and modality.

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Annual Cost to Federal Government: $107,800

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/01/2014

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