SSA-21

Supplement To Claim Of Person Outside Of United States

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SUPPLEMENT TO CLAIM OF PERSON OUTSIDE THE UNITED STATES
(To be completed by or on behalf of personwho is,was,or will be outside the U.S.)
For Social Security purposes, a person is outside the United States if he or she is physically outside the 50 States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa.

1. NAME OF WORKER ON WHOSE EARNINGS THIS CLAIM IS BASED

2. WORKER'S SOCIAL SECURITY NUMBER --

3. COUNTRY WHERE YOU LIVE LIST BELOW THE FULL NAME OF THE WORKER (EVEN IF DECEASED) AND OFEACH BENEFICIARY IN THE SAME HOUSEHOLD WHO IS, WAS OR WILL BE OUTSIDE THE UNITED STATES. IF PERSON HAS U.S. PASSPORT, LIST: COUNTRY OF BIRTH OVER NEXT 12 MONTHS PRESENT DATE ISSUED COUNTRY(IES) OFPRESENT CITIZENSHIP (Or at time of death) PASSPORT NO.
a.
b.
c.
d.
Note:
All persons listed above or their representative payees must sign the certification in item 18.
If any beneficiary listed in item 3 was outside the U.S. this month or any of the past 24 months, or will be in the next 6 months,complete item 4 by entering the name of the beneficiary and dates (month, day and year) he or she was or will be outside the U.S.

NOTE: Entries should not be made by residents of Canada or Mexico who are entering the U.S. on a daily basis to work or visit and returning each day to their residence in Canada or Mexico.

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