This form contains 48 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Applicant Information
4. Applican't Name	Text	Enter the full name of the applicant requesting the employment information.
Applicant's Social Security Number first three digits	Text	Enter the first three digits of the applicant's Social Security Number. Max length: 3 characters
Applicant's Social Security Number middle two digits	Text	Enter the middle two digits of the applicant's Social Security Number. Max length: 2 characters
Applicant's Social Security Number last four digits	Text	Enter the last four digits of the applicant's Social Security Number. Max length: 4 characters
Coverage Details
Year	Text	Enter the year when the applicant's coverage began. Max length: 4 characters
Yes or No	CheckBox	Select 'Yes' if the applicant's coverage began on the specified date.
Yes or No	CheckBox	Select 'No' if the applicant's coverage did not begin on the specified date.
Month	Text	Enter the month when the applicant's coverage began. Max length: 2 characters
Month	Text	Enter the year when the applicant's coverage began. Max length: 4 characters
Month	Text	Enter the month when the applicant's coverage started. Max length: 2 characters
Year	Text	Enter the year when the applicant's coverage started. Max length: 4 characters
Month	Text	Enter the month when the applicant's coverage ended. Max length: 2 characters
Year	Text	Enter the year when the applicant's coverage ended. Max length: 4 characters
Coverage Information
Month	Text	If applicable, enter the month when the applicant's coverage began. Use a two-digit format (MM). Max length: 2 characters
Date Information
Month	Text	Enter the month of the date related to the form (e.g., date of employment or coverage). Use a two-digit format (MM). Max length: 2 characters
Day	Text	Enter the day of the date related to the form (e.g., date of employment or coverage). Use a two-digit format (DD). Max length: 2 characters
Year	Text	Enter the year of the date related to the form (e.g., date of employment or coverage). Use a four-digit format (YYYY). Max length: 4 characters
Employee Information
6. Employee’s Name	Text	Enter the full name of the employee (if different from the applicant) who is or was covered by the group health plan.
Applicant's Social Security Number first three digits	Text	Enter the first three digits of the employee's Social Security Number. Max length: 3 characters
Employee's Social Security Number middle two digits	Text	Enter the middle two digits of the employee's Social Security Number. Max length: 2 characters
Employee's Social Security Number last four digits	Text	Enter the last four digits of the employee's Social Security Number. Max length: 4 characters
Employer Contact Information
Area Code	Text	Enter the area code of the phone number for the company official. Max length: 3 characters
Phone Number three digits	Text	Enter the first three digits of the phone number for the company official. Max length: 3 characters
Phone Number four digits	Text	Enter the last four digits of the phone number for the company official. Max length: 4 characters
Employer Information
1. Employer's Name	Text	Enter the name of the employer providing the group health plan coverage.
3. Employer's Address	Text	Enter the full address of the employer providing the group health plan coverage.
City	Text	Enter the city where the employer is located.
State	Text	Enter the state where the employer is located. Use the two-letter state abbreviation. Max length: 2 characters
Zip Code	Text	Enter the ZIP code of the employer's address. Use a five-digit format. Max length: 5 characters
Title of Company Official	Text	Enter the title of the company official who is completing Section B of this form.
Employment Details
Month	Text	Enter the month when the applicant's current employment began. Max length: 2 characters
Year	Text	Enter the year when the applicant's current employment began. Max length: 4 characters
Month	Text	Enter the month when the applicant's previous employment began. Max length: 2 characters
Year	Text	Enter the year when the applicant's previous employment began. Max length: 4 characters
Month	Text	Enter the month when the applicant's previous employment ended. Max length: 2 characters
Year	Text	Enter the year when the applicant's previous employment ended. Max length: 4 characters
Form Signing Date
Month	Text	Enter the month when this form was signed. Max length: 2 characters
Day	Text	Enter the day when this form was signed. Max length: 2 characters
Year	Text	Enter the year when this form was signed. Max length: 4 characters
Hours Bank Arrangements
Yes or No	CheckBox	Select 'Yes' if the applicant has an hours bank arrangement.
Yes or No	CheckBox	Select 'No' if the applicant does not have an hours bank arrangement.
Yes or No	CheckBox	Select 'Yes' if the applicant's hours bank arrangement is still active.
Yes or No	CheckBox	Indicate whether the hours bank arrangement applies by checking 'Yes' or 'No'.
Questionnaire
Yes or No	CheckBox	Check this box if the answer to the question is 'Yes'.
Yes or No	CheckBox	Check this box if the answer to the question is 'No'.
Reserve Hours
Month	Text	Enter the month when the reserve hours ended or will be used. Max length: 2 characters
Year	Text	Enter the year when the reserve hours ended or will be used. Max length: 4 characters
Validation
Signature1	Signature	Provide your signature to validate the information provided in this form.

Form CMS L564, Request for Employment Info Instructions