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

SOCIAL SECURITY

Office of Operations

Social Security Administration

Operations Analysis Section

1200 Rev. Abraham Woods Jr. Blvd.

Birmingham, AL 35285-0001

Date:

Claim Number:

Mr. John Smith

123 Main Street

Baltimore, MD 21230

Dear Mr. Smith:

We are writing to you about (fill-in with your or beneficiary’s name possessive) work and earnings for (fill-in with year(s)).

Medical Resident Tax Refund Claims

(Fill-in with You or beneficiary’s name) consented for (fill-in with your, his, or her) employer to file a refund claim on (fill-in with your, his, or her) behalf. The refund claim is for Federal Insurance Contributions Act (FICA) taxes that (fill-in with your, his, or her) employer withheld from wages (fill-in with you, he, or she) earned as a medical resident for 2001 through 2004. FICA taxes are Social Security and Medicare taxes.

A Refund Will Affect (Fill-in with Your or beneficiary name possessive) Social Security Benefits

We will lower (fill-in with your or beneficiary name possessive) benefit amount to (fill-in

$ amount) if (fill-in with you, he, or she) (fill-in with receive or receives) a refund of FICA taxes. If (fill-in with you or beneficiary name) (fill-in with have or has) a spouse or children receiving benefits, we will also lower their benefit amounts.

What (Fill-in with You or Beneficiary Name) (Fill-in with Need or Needs) to Do

Please decide whether (fill-in with you or beneficiary’s name) still (fill-in with want or wants) to receive a refund of (fill-in with your, his, or her) taxes or if (fill-in with you or beneficiary name) (fill-in with wish or wishes) to withdraw (fill-in with your, his, or her) refund claim in order to keep (fill-in with your, his, or her) current benefit amount(s). Please complete, sign, and return the enclosed form SSA-795-OP2 in the enclosed envelope. It is important that (fill-in with you or beneficiary name) return the signed form to us within 10 days of the date (fill-in with you or beneficiary name) received this letter.

What Will Happen

If you decide you do not want the refund, we will share (fill-in with your or beneficiary name possessive) response with the Internal Revenue Service (IRS). Once (fill-in with you or beneficiary name) (fill-in with have or has) submitted the signed, enclosed form, no further action is required on (fill-in with your, his, or her) part. If we do not receive the form within 10 days, we will assume (fill-in with you or beneficiary name) (fill-in with want or wants) to continue with (fill-in with your, his, or her) refund claim and the IRS will pay (fill-in with you or beneficiary name) (fill-in with your, his, or her) refund, even though this will affect (fill-in with your, his, or her) benefits.

If (Fill-in with You or Beneficiary Name) (Fill-in with Have or Has) Questions

If (fill-in with you or beneficiary name) (fill-in with have or has) specific questions about this letter, please call us toll-free at 1-800-254-9491 and enter extension 32240.

We invite (fill-in with you or beneficiary name) to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. We can answer most questions over the phone. For general questions, please call us toll-free at 1-800-772-1213. (Fill in with Your or Beneficiary name possessive) local Social Security office is located at Suite 200, 1010 Park Avenue, Baltimore, MD 21201. If (fill-in with you or beneficiary name) (fill-in with are or is) deaf or hard of hearing, (fill-in with you, he, or she) may call our TTY number, 1-800-325-0778.

If (fill-in with you or beneficiary name) (fill-in with have or has) specific questions about (fill-in with your, his or her) refund, please call the IRS toll-free at 1-800-919-1703.

[Fill-in with PSC Director’s Signature (ARC, PCO)]

Enclosure: Form SSA-795-OP2

.

SOCIAL SECURITY ADMINISTRATION BALTIMORE, MD 21235-0001