Form Cms-R285 - Request For Retirement Benefit Information

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0769

REQUEST FOR RETIREMENT BENEFIT INFORMATION

Employee’s Name

Employee’s Social Security Number

Employer’s Name

Employer’s Address

Claimant’s Name

Claimant’s Social Security Number

We need the information listed below in connection with _______________________________________

(claimant’s name)

1. Is the claimant receiving retirement payments based on his/her own State or

local government employment?

YES

2. Is the claimant the spouse, divorced spouse, widow or widower of a person who is

receiving (or did receive) retirement payments based on his/her own State or local

government employment?

YES

3. How long did the claimant (or spouse) work for the State or local government employer?

Beginning Date

Last Date of Employment

4. Has the pension plan or former employer subsidized the claimant’s Medicare Part A

premium in whole or in Part for any month during the past 7 years?

YES

5. If the claimant is found to be eligible for the reduced Medicare Part A premium,

will his/her retirement payments be adjusted or recalculated?

YES

I certify that the statements given above are true. I know that anyone who makes a false statement or

representation of a material fact for use in determining a right to payment under the Social Security Act

commits a crime punishable under Federal law.

Signature of Official

Title of Official

Telephone Number

Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938-0769. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to search

existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions

for improving this form, please write to CMS, 7500 Security Boulevard, Attn: Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R285 (03/06)