Consent to Participate in Medical Resident FICA Refund Claim
In order to participate in the refund claim, you will need to complete the “Duke University - Medical Resident Consent Form” and affirm, in writing, to the following:
I, personally, have not claimed and will not claim a refund or credit from the IRS for any FICA taxes from wages paid for services performed as a medical resident, or if I have, the claim was rejected.
I, personally, did not receive a FICA tax refund or credit because I earned in excess of the social security wage base on my Federal income tax return (e.g., Form 1040). For information concerning partial FICA refunds, please see the Frequently asked Questions on the website)
I understand that my Social Security earnings record will be corrected to reflect zero wages earned as a medical resident for tax periods for which I received a refund. I understand that removing these wages could affect my or my dependents’, eligibility to or the amount of future Social Security (disability, survivors, or retirement) benefits.
I give my consent to Duke University to file a Medical Resident FICA Refund Claim on my behalf for refunds of eligible FICA taxes that Duke University withheld from my wages for services I performed as a medical resident.
I understand that completing this form does not guarantee that I will receive a refund. The refund claim is subject to IRS approval and the IRS may determine I am not eligible.
I understand that if I am not a US citizen, permanent resident or resident alien, Duke may be required to withhold US income tax on the interest portion of any refund that I receive. I have correctly stated my citizenship/residency status above and will notify Duke if my citizenship or residency status changes prior to the finalization of this process.
to view and print the “Duke University - Medical Resident Consent Form”
Upon completion of the form, please mail your signed form by October 29, 2010 to:
C/O Ernst & Young LLP, Attn.: Robin Davidson
99 Wood Avenue South, Iselin, NJ 08830
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This information is not intended for use without professional advice.