Information Collection

Request for Retirement Benefit Informatin

IC 8511 under ICR 201309-0938-016 · OMB 0938-0769.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0769 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-285 Request for Retirement Benefit Informatin	Form
CMS-R-285 Request for Retirement Benefit Information CMSR285-508.pdf	Form

IC Title:

Request for Retirement Benefit Informatin

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-285	Request for Retirement Benefit Information	CMSR285-508.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	500	-1,000	1,500
Annual IC Time Burden (Hours)	125	-250	375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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