FICA Release Form | UVA Finance

This form allows University of Virginia employees to acknowledge and certify their understanding of a FICA (Social Security and Medicare) tax refund related to a prior-year salary overpayment, as required under Treasury Regulation § 31.6402(a)-2. By submitting this form, the employee certifies they will not separately claim this refunded amount from the IRS.

Acknowledgement and Statement

Pursuant to Treasury Regulation § 31.6402(a)-2 Regarding Overpayments to Employees

Prior calendar year in which salary was overpaid

This form documents my understanding that I am entitled to receive a refund of FICA (Social Security and Medicare) taxes from the University of Virginia upon my repayment of the overpaid amount. I also understand that the gross amount that I am required to repay has been reduced by the amount of FICA taxes refunded to me.

Further, I certify that I have not and will not claim a refund or credit for this same amount of refunded FICA taxes from the IRS since I am already receiving that amount directly from the University of Virginia.

Employee ID Number

Employee Email Address

Signature (type your full legal name)

I certify that the typed name above is my electronic signature, that I have read the Acknowledgement and Statement, and that I agree to it.

Date

CAPTCHA

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Payroll

Personal Payroll Activities

Sales & VAT Tax

Academic Division

UVA Affiliation or Organization

FI-Payroll Operations