A signed statement from the claimant/beneficiary (or payee) showing:
               
                  - 
                     
                        • 
                           the individual considers themselves to be a U.S. resident; 
 
 
- 
                     
                        • 
                           whether the individual has ever notified Department of Homeland Security (DHS) that
                              they had abandoned their U.S. residence, and if so, when;
                            
 
 
- 
                     
                        • 
                           whether the individual has ever been notified by DHS that the individual no longer
                              had U.S. resident status, and if so, the date;
                            
 
 
- 
                     
                        • 
                           the individual understands that as a U.S. resident their worldwide income will be
                              subject to U.S. income tax in the same manner as that of persons living in the U.S.;
                              and
                            
 
 
- 
                     
                        • 
                           the individual will notify SSA promptly if their 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 the I-551 as evidence of their 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 the individual 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.