Fillable DFS-A3-1932 FICA Refund Request (Florida Department of Financial Services)

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DFS-A3-1932 FICA Refund Request (Florida Department of Financial Services)

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DFS-A3-1932 (Rev. 5/16/13)

FICAREFUNDREQUEST

OR

OPSFICAALTERNATIVERETIREMENTPLANCONTRIBUTIONREFUNDREQUEST



TheemployingagencymustcompletePartIandIItorequestarefundofFederalInsuranceContribution

Act(FICA)taxes,alsoknownasSocialSecurity(Old‐Age,Survivors,andDisabilityInsurance)and

Medicareand/ortorequestarefundoftheemployee’scontributiontotheOPSFICAAlternative

RetirementPlan.TheemployeeneedstosignPartIIIiftherefundrequestedisforprioryearFICAtaxes.



PartI.Tobecompletedandsignedbyemployingagency

LastName FirstName MiddleInitial

Last4digitsofSocialSecurityNumber DatesemployeeiseligibleforarefundofSocialSecurityand/or

Medicaretax

XXX‐XX‐ From: To:

Checkallthatapply:



 RefundofSocialSecurityTaxes 

 RefundofMedicareTaxes 

 RefundofOPSFICAAlternativeRetirementPlanContribution  

Agency29‐digitFLAIRaccountcodeinwhichtheagency'smatchingrefundshouldberestored

____‐____‐__‐____________‐________________‐____‐____________‐____

AgencyPreparer'sName(printed) AgencyPreparer'sTitle

AgencyPreparer'sName(signed) Date Phone:

Email:



PartII.Reasonemployeeiseligibleforrefund

Dualemployment

 IndividualisanOPSemployeethatalsoholdsasalariedposition,buthasNOTbeen

continuouslyemployedbytheStateofFloridaasasalariedemployeesincepriortoApril1,

1986.CorrectretirementcodeisZM.

 IndividualisanOPSemployeethatalsoholdsacareerserviceposition.Employeehasbeen

continuouslyemployedbytheStateofFloridaasasalaried(notOPS)sincepriortoApril1,

1986.CorrectretirementcodeisZX.

Rehiredretiree

 IndividualisanOPSemployeethatretiredfromaFloridaRetirementSystememployerand has

beguntoreceivebenefitsfromthesystemorhasreachednormalretirementageunderthe

plan.CorrectretirementcodeisZM.

OPSeligibletoparticipateintheOPSFICAAlternativeRetirementPlan

 IndividualisatemporaryorseasonalOtherPersonnelServicesemployeethatdoesotherwise

meetcriteriatobeexemptfromthealternativeplan.Correctretirementcodeis ZA.

OtherperInternalRevenueCode§3121(b)(7)(F)

 Employeeisaclient,inmateorresidentofaStatehospital,home,orinstitution.Correct

retirementcodeisZX.

 Employeeishiredtorelieveanindividualfromunemployment.CorrectretirementcodeisZX.

 Employeehiredtemporarilyforemergenciesornaturaldisasters.CorrectretirementcodeisZX.



PartII.Reasonemployeeiseligibleforrefund (continued)

Nonresidentalien

 IndividualisanonresidentalienthatqualifiesforInternalRevenueCode§3121(b)(19)

exemptionbymeetingall ofthefollowingqualifications:



TheydonotpossessanUSCISFormI‐551,PermanentResidentCard(greencard)



Theydonotsatisfythesubstantialpresence test(SeeIRSPub515)



TheyarepresentintheU.S.underanF‐1,J‐1,M‐1,orQ‐1visa,and



Theyareperformingservicesinaccordancewiththeprimarypurposeofthevisa’sissuance

 Correctretirementcodeis(circleone):ZXHDHFONPDPF

*BureauofStatePayrollsmayrequestadditionalinformationtoverifyeligibility



PartIII.Tobecompletedandsignedbyemployeeifrefundrequestedisfora

priorcalendaryear



Underpenaltyofperjury,I,(employee),havenotandwillnot

requestarefundorcreditformy(yearsoverpaid)overpaymentofSocialSecurity

and/orMedicaretaxesfromtheInternalRevenueService.Anyrefundorcreditalreadysoughthas

beenrejected.



 

Employee'sSignature:

Date:

  



PartIV.Additionalinformation



AdditionalMedicareTax:  

BeginningJanuary1,2013,theAffordableCareActadded§3101(b)(2).ThisincreasestheMedicaretax

byanadditional0.9%foremployeecontributionsonwagesthatexceedathreshold,whichiscurrently

$200,000.ThereisnoadditionalMedicaretaxforemployersonwagesthatexceedthisthreshold.The

proceduralrulesstatethatprioryearadjustmentsaretobetreatedlikeFederalIncomeWithholding

tax.Therefore,BOSPwillnotprocessrefundsforprioryearadditionalMedicaretaxamounts.The

employeeistoreconcilethedifferencewhenfilingtheirIndividualIncomeTaxReturn.



RetirementCodeAdjustments: 

Itmaybenecessarytoprocessanonlineretirementadjustmentiftheemployeewaspreviously

enrolledinanFRSretirementplanthatrequiredanemployeecontributionwhichwasdeductedfrom

theirpayundertheincorrectretirementcode.Theemployeewouldbeduearefundfortheemployee

contributionamountwhichwasdeducted,ifthenewretirementcodedoesnotalsorequirean

employeecontributionamount.



DFS-A3-1932 (Rev. 5/16/13)

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