A signed statement from the claimant/beneficiary (or payee) showing:
he/she considers himself/herself to be a U.S. resident;
whether he/she has ever notified Department of Homeland Security (DHS) that he/she
had abandoned his/her U.S. residence, and if so, when;
whether he/she has ever been notified by DHS that he/she no longer had U.S. resident
status, and if so, the date;
he/she understands that as a U.S. resident his/her worldwide income will be subject
to U.S. income tax in the same manner as that of persons living in the U.S.; and
he/she will notify SSA promptly if his/her U.S. resident status is abandoned or revoked.
NOTE: As used in this chapter, “I-551” includes all versions of the form and the I-151.
If the claimant/beneficiary does not submit his/her I-551 as evidence of his/her U.S.
resident status (as required by GN 05010.030C.2.), the statement must also show whether that I-551 was taken by DHS.
This statement may be on an application, SSA-795 or other form.
A separate statement is not necessary if he/she completes questions 10-14 on the SSA-21,
since these questions are to be answered only by claimants/beneficiaries who want
to be considered U.S. residents for alien tax purposes and the explanation of the
tax, on this form, includes the taxation of worldwide income.