View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0769	ICR Reference No: 202012-0938-017
Status: Historical Active	Previous ICR Reference No: 201707-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Retirement Benefit Information (CMS-R-285)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/30/2021
	Date Received in OIRA: 12/29/2020
Terms of Clearance: CMS will consider ways to improve the use of technology and the beneficiary experience in submitting this form before the next approval period.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2024	36 Months From Approved	04/30/2021
Responses	500	0	500
Time Burden (Hours)	125	0	125
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $1,101

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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