COMPLETE ITEMS 9 THROUGH 13 ABOUT ALL PERSONS LISTED IN ITEM 3 WHO ARE NOT U.S.
CITIZENS AND WANT TO BE CONSIDERED U.S. RESIDENTS FOR INCOME TAX PURPOSES.
NAME
Enter below the name of all persons listed in item 3 who believe they will have U.S resident status while living outside the
U.S. Also show the number of each person's Permanent Resident Card (sometimes referred to as a Green Card) and the
date that card was issued. If any person was not lawfully admitted for permanent residence, show "None" and explain why
he or she is a U.S. resident in the "REMARKS" section on page 4.
NAME
Date (Mo-Yr)
NAME
Date (Mo-Yr)
Enter the name(s) of any person(s) listed in item 9 who has ever notified the U.S. government, by letter or formal
application, that he or she has abandoned, or wishes to abandon, his or her U.S. residence status, or has commenced to be
treated as a resident of a foreign country under the provisions of a tax treaty between the U.S. and the foreign country.
10.
DATE CARD WAS
ISSUED
PERMANENT RESIDENT CARD
(GREEN CARD) NUMBER
9.
6.
7.
8.
Supplementary Medical Insurance generally is payable only for medical services provided inside the U.S. If anyone listed in
item 3 is now enrolled in Supplementary Medical Insurance under Medicare and wishes to terminate that enrollment, enter
his or her name here. If you need more space, use the ”REMARKS” section on page 4.
Does any person listed in item 3 expect to begin employment or self-employment outside the
U.S. in the future? If "yes," give name(s) and date(s) work is expected to begin.
If you need
more space, use the “REMARKS” section on page 4.
Answer item 7 only if the worker named in item 1 is deceased. Did the worker die while in the
military service of the U.S. or as a result of disease or injury incurred or made worse while in
military service?
YES NO
NAME
NAME(S)
Form SSA-21 (05-2018) UF Page 2 of 5
The U.S. Internal Revenue Code (IRC) requires the Social Security Administration (SSA) to withhold a 30 percent Federal
income tax from 85 percent of monthly retirement, survivors and disability benefits paid to beneficiaries who are neither
citizens nor residents of the United States. This results in an effective tax of 25.5 percent of the monthly benefit. SSA must
withhold this tax from the benefits of all nonresident aliens except those who are residents of countries that have tax treaties
with the U.S. that provide an exemption from this tax, or a lower rate of withholding. Currently these countries are Canada,
Egypt, Germany, India, Ireland, Israel, Italy, Japan, Romania, Switzerland, and the United Kingdom. For details and
changes regarding income tax treaties, you may check with the Internal Revenue Service.
For Federal income tax purposes, a person can be considered a U.S. resident, even if that person lives outside the United
States, if he or she:
• Has not claimed a tax treaty benefit as a resident of a country other than the United States in the same year; AND
• Has been lawfully admitted to the United States for permanent residence and that residence has not been revoked
or determined to have been administratively or judicially abandoned; OR
• Meets a substantial presence test as defined by the IRC. To meet this test in a given year, the person must be
present in the U.S. on at least 31 days in that year, and a minimum total of 183 days counting all the days of U.S.
presence in that year, one-third of the total number of days of U.S. presence in the previous year, and one-sixth of
the total number of days of U.S. presence in the year before that. (The IRC defines days of U.S. presence and
exclusions for applying the substantial presence test.)
If you are a U.S. resident alien for Federal income tax purposes, generally your worldwide income is subject to U.S. income
tax, regardless of where you are living.
Date (Mo - Yr)
Date (Mo - Yr)
NAME
NOYES