Information Collection

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

IC 196180 under ICR 201102-0960-006 · OMB 0960-0786.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.