Information Collection

Application For Exemption From Social Security And Medicare Taxes And Waiver Of Benefits

IC 128263 under ICR 199107-1545-009 · OMB 1545-0064.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-0064 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	APPLICATION FOR EXEMPTION FROM SOCIAL SECURITY AND MEDICARE TAXES AND WAIVER OF BENEFITS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4029				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,754	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,754	-101	-4,361	8,216
Annual IC Time Burden (Hours)	3,942	-112	-4,819	8,873
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.