Information Collection

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

IC 187515 under ICR 202103-0960-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0051 Privacy Act Statement (revised).docx Other-Revised PA Statement
0051 PRA Statement (revised).docx Other-Paper Reduction Act Statement
SSA-21 Supplement to Claim of person Outside the United States SSA-21 (revised).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: 42 CFR 407.27(c) 20 CFR 404.463 20 CFR 422.505(b) 20 CFR 404.460

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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).pdf	Yes	No	Fillable Printable
Other-Revised PA Statement			0051 Privacy Act Statement (revised).docx	Yes	No	Fillable Printable
Other-Paper Reduction Act Statement revised			0051 PRA Statement (revised).docx	No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	360	-150	510
Annual IC Time Burden (Hours)	84	-35	119
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-21	SSA-21 (current).pdf	04/28/2021

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