OMB.report

Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form
Other-Cover Letter
Other-Cover Letter
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Statement of Claimant or Other Person-Medical Resident FICA Refund Claims
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.570 20 CFR 404.702

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted 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

Income Security General Retirement and Disability

 

496 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 496 0 0 0 0 496
Annual IC Time Burden (Hours) 33 0 0 0 0 33
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.