Addendum to Supporting Statement SSA-795-OP2

Addendum to the Supporting Statement for SSA-795-OP2

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

20 CFR 404.702, 20 CFR 416.570

OMB No. 0960-0786

Justification for Resubmission of the Collection within One Year of OMB Approval

On May 3, 2011, OMB approved the emergency clearance for SSA to use form SSA-795-OP2 (Statement of Claimant or Other Person-Medical Resident FICA Refund Claims) and its accompanying cover letters, to contact medical residents (residents). We requested the emergency clearance so the IRS could issue the FICA refunds to the residents (or their beneficiaries) immediately after we notify them of those who decided to revoke their request for the refund. The emergency clearance allows SSA to use form SSA-795-OP2 until November 30, 2011.

The IRS is providing SSA (on a flow basis as they complete the refund claims) with identifying data to contact the residents that are currently entitled to benefits. We are requesting full clearance of the current emergency clearance. We want to ensure that the collection is available since we cannot control when the IRS sends us the information we need to contact the residents.

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the first page of the form.