Santa Clara — HR-052*

Source: https://santaclara.courts.ca.gov/system/files/hr/hr-052_rem.pdf

Superior Court of California County of Santa Clara Human Resources 191 North First Street San José, CA 95113 Telephone: (408) 882-2703 Fax: (408) 882-2796 Email: RetireeBenefits@scscourt.org

CERTIFICATION OF MEDICARE STATUS

This form is being completed for: Court Retiree Dependent of Retiree Survivor of Retiree

Please complete Section 1, 5 (if applicable), 6 and either Section 2, 3, or 4. Sign and date the form and return it to: Superior Court of California, County of Santa Clara 191 North First Street, San José, CA 95113.

SECTION 1: Please complete the following information Name: (Last Name, First Name) Retiree’s ID or last 4 of SSN:

SECTION 2: For Retiree or Dependent/Survivor of Retiree enrolled in Medicare Part A and B I am enrolled in Medicare Part A and Medicare Part B. This is the information reflected on my red, white and blue Medicare card or Notice of Entitlement from the Social Security Administration (please attach copy):

Medical Claim Number:

HOSPITAL (PART A) effective date:

MEDICAL (PART B) effective date

SECTION 3: For Retiree or Dependent/Survivor of Retiree claiming Medicare Ineligibility I am not eligible for Medicare Part A (in my own right or through the work history of a current, former, or deceased spouse). I have verified this with the Social Security Administration and have attached documentation of this fact.

SECTION 4: For Retiree or Dependent/Survivor of Retiree who works and has Employer Group Health Plan Coverage I have deferred Medicare Part B enrollment due to working beyond age 65 and have coverage in my/my spouse’s Employer Group Health Plan. I have attached documentation of this fact.

1. Name of current Employer:

2. Name of Group Health Plan provided by employer:

SECTION 5: For Retiree ONLY – Requirement to enroll in Medicare Statement of Understanding I understand once I am enrolled in Medicare Part B, I must contact Human Resources and enroll in a Medicare plan. Should I no longer be enrolled in Medicare Part B or become ineligible for Medicare Part B, I will notify Human Resources immediately.

SECTION 6: Retiree or Dependent/Survivor of Retiree Signature I certify that the above information is true and correct and that I have read and understood these requirements.

SIGN

Signature Date

HR-052 Rev. 3/2025