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

ICR 202012-0938-017

OMB: 0938-0769

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2020-12-23
Supplementary Document
2013-09-08
IC Document Collections
IC ID
Document
Title
Status
8511 Modified
ICR Details
0938-0769 202012-0938-017
Received in OIRA 201707-0938-005
HHS/CMS CM-CPC
Request for Retirement Benefit Information (CMS-R-285)
Extension without change of a currently approved collection   No
Regular 12/29/2020
  Requested Previously Approved
36 Months From Approved 02/28/2021
500 500
125 125
0 0

This information is needed to determine whether a beneficiary meets the requirements for reduction of the Part A premium to zero.

Statute at Large: 18 Stat. 1818 Name of Statute: null
  
None

Not associated with rulemaking

  85 FR 60170 09/24/2020
85 FR 83966 12/23/2020
No

1
IC Title Form No. Form Name
Request for Retirement Benefit Informatin CMS-R-285 Request for Retirement Benefit Information

  Total Request 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 500 500 0 0 0 0
Annual Time Burden (Hours) 125 125 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$1,101
No
    Yes
    No
No
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  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.
12/29/2020


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