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

Forms and Documents

Document Name	Status
Form SSA-795-OP2 Statement of Claimant or Other Person-Medical Resident FICA Refund Claims Form	New
OMB No. 0960-NEW (Medical IRS Resident Issue) - emergency request letter.docx Supplementary Document	2011-04-06
Supporting Statement - 0960-NEW (SSA-795-OP2).docx Supporting Statement A	2011-04-06

IC Document Collections

IC ID	Document Title	Status
196180	Statement of Claimant or Other Person-Medical Resident FICA Refund Claims Form	New

ICR Details

OMB Control No: 0960-0786	ICR Reference No: 201102-0960-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Claimant or Other Person-Medical Resident FICA Refund Claims
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/14/2011
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/03/2011
	Date Received in OIRA: 04/06/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2011	6 Months From Approved
Responses	496	0	0
Time Burden (Hours)	33	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: SSA will use this collection to perform an outreach to those medical residents (or their survivors, next of kin, representative payee, etc.) currently entitled to Social Security benefits whose benefits will be affected if they accept a refund of FICA taxes from IRS. This collection is voluntary for respondents, because they are not required to complete the collection to obtain or keep a specific benefit. SSA will call the residents and explain how accepting the refund will affect their Social Security benefits. We will then mail the SSA-795-OP2 to each resident to sign and return to SSA. If SSA cannot reach the resident by phone, we will send a contact letter and the SSA-795-OP2 to the resident to complete and return to SSA. SSA plans to use Form SSA-795-OP2 immediately upon approval and continue to use it for approximately 1 year, during which SSA employees from the Southeastern Program Service Center will only collect this information once per respondent. Once we have the information, we will forward the signed forms to the IRS for the residents who no longer want the FICA refund. The respondents are medical residents who requested a FICA refund from the IRS for their services as a resident during the period of 1993 through 2005.

Emergency Justfication: As per our discussion with OMB, the Social Security Administration (SSA) is requesting emergency clearance for Form SSA-795-OP2, Statement of Claimant or Other Person–Medical Resident FICA Refund Claims. The IRS agreed to postpone issuing the FICA refunds for the residents until we identify those currently entitled to benefits. To document the residents’ decision to accept or revoke the refund, SSA proposes to send a cover letter and form SSA-795-OP2 to the residents to complete and sign. We expect to use the SSA-795-OP2 immediately upon approval and will continue to use it for approximately 1 year. This is a one-time information collection. We will use the SSA-795-OP2 to document our contact with medical residents who are currently entitled to benefits and whose benefits we would need to eliminate or reduce if they accept the IRS refund. If the residents decide to take the refund, SSA will remove the earnings from their earnings record (for the period of the refund) and will lower the residents’ monthly benefit amount. We will fax the signed SSA-795-OP2 to the IRS to notify them of residents who have decided to revoke their request for the refund. SSA will maintain copies of all signed SSA-795-OP2 forms in our Non-Disability Repository for Evidentiary Documents.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 17978	03/31/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Statement of Claimant or Other Person-Medical Resident FICA Refund Claims	SSA-795-OP2	Statement of Claimant or Other Person-Medical Resident FICA Refund Claims

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ICR Summary of Burden

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

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This new form increases the public reporting burden. See the chart above for burden figures.

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Annual Cost to Federal Government: $11,789

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/06/2011

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