Information Collection

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

IC 196180 under ICR 201107-0960-002 · OMB 0960-0786.

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 5-5-11 (2).pdf	Form
SSA-795-OP2Master 5-5-11 (2).pdf SSA-795-OP2 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 5-5-11 (2).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	Previously Approved
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
SSA-795-OP2 (current)	SSA-795-OP2Master 5-5-11 (2).pdf	09/28/2011

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