Request for Retirement Benefit Informatin

Request for Retirement Benefit Information (CMS-R-285)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-R-285 Request for Retirement Benefit Informatin Form
CMS-R-285 Request for Retirement Benefit Information CMS-R-285 2017 [508].pdf Form

Information Collection (IC) Details

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:

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	CMS-R-285 2017 [508].pdf		No		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 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.