Request for Employment Information (CMS-R-297/CMS-L564)

OMB 0938-0787

OMB 0938-0787

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.

The latest form for Request for Employment Information (CMS-R-297/CMS-L564) expires 2023-06-30 and can be found here.

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All Historical Document Collections
Approved without change
 Extension without change of a currently approved collection 2023-05-31
Approved with change
 Reinstatement without change of a previously approved collection 2020-03-24
Approved with change
 Extension without change of a currently approved collection 2016-09-29
Approved without change
 Revision of a currently approved collection 2014-01-06
Approved without change
 Extension without change of a currently approved collection 2013-08-07
Approved without change
 Extension without change of a currently approved collection 2010-07-22
Approved without change
 Extension without change of a currently approved collection 2007-07-13
Approved without change
 Extension without change of a currently approved collection 2004-06-07
Approved without change
 Extension without change of a currently approved collection 2001-06-15
Approved without change
 Existing collection in use without an OMB Control Number 2000-01-06
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