Statement of Claimant or Other Person-Medical Resident FICA Refund Claims

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0786 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-795-OP2 Statement of Claimant or Other Person-Medical Resident FICA Refund Claims Form
Cover Letter for SSA-795-OP2.approval.dotx.docx Other-Cover Letter
Cover Letter for SSA-795-OP2.fill in.approval.dotx.docx Other-Cover Letter
SSA-795-OP2 Statement of Claimant or Other Person-Medical Resident F SSA-795-OP2Master 2-23-11.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Claimant or Other Person-Medical Resident FICA Refund Claims	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.570 20 CFR 404.702

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-795-OP2	Statement of Claimant or Other Person-Medical Resident FICA Refund Claims	SSA-795-OP2Master 2-23-11.pdf	No	Paper Only
Other-Cover Letter			Cover Letter for SSA-795-OP2.approval.dotx.docx	No	Paper Only
Other-Cover Letter			Cover Letter for SSA-795-OP2.fill in.approval.dotx.docx	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 496	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	496	496
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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