Request for Employment Information

ICR 201007-0938-010

OMB: 0938-0787

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2010-07-08
IC Document Collections
ICR Details
0938-0787 201007-0938-010
Historical Active 200707-0938-004
HHS/CMS
Request for Employment Information
Extension without change of a currently approved collection   No
Regular
Approved without change 08/29/2010
Retrieve Notice of Action (NOA) 07/22/2010
  Inventory as of this Action Requested Previously Approved
08/31/2013 36 Months From Approved 09/30/2010
5,000 0 5,000
1,250 0 1,250
0 0 0

This information is needed to determine whether an individual is eligible to enroll in Medicare Part B or Premium Part A under the provisions of section 1837(i) of the Social Security Act (The Act) and/or qualify for a reduction in the premium amount under the provisions of section 1839(b) of the Act.

US Code: 42 USC 1395p Name of Law: Enrollment Periods
  
None

Not associated with rulemaking

  75 FR 20366 04/19/2010
75 FR 38530 07/02/2010
No

1
IC Title Form No. Form Name
Request for Employment Information (CMS-R-297) CMS-R_297 Request For Employment Information

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,000 5,000 0 0 0 0
Annual Time Burden (Hours) 1,250 1,250 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$10,500
No
No
No
Uncollected
No
Uncollected
Bonnie Harkless 4107865666

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/22/2010


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