August 28, 2008
Extended repayment schedule request for a sole proprietor
To consider an extended repayment schedule (ERS) request for a sole proprietor, the following documentation is required:
1. Rationale detailing the request for an extended repayment schedule.
2. Completely fill out and return the Financial Statement of Debtor form (CMS-379) using the words "none" or "not applicable (NA)" where appropriate. This form is located on the CMS Web site at: www.cms.hhs.gov/cmsforms/downloads/CMS379.pdf 
3. A copy of your complete federal income tax return for the most recent year including all attachments and schedules.
4. An amortization schedule, not to exceed 60 months. This schedule must contain the proposed repayment plan, including length of the plan, dates of repayment, and payment amount broken down between principal and interest for the life of the schedule.
5. A copy of one loan application for the amount of the overpayment with a denial letter from the bank. This is only required for extended repayment requests for more than 12 months.
6. 1099 Form for the period of the overpaid dates. If the overpayments occurred in the current year, since the 1099 would not yet be available, the previous year's 1099 should be provided.
Please FAX all documentation to 904-361-0664. You will be advised of the decision after a review of the information is completed.
If you send in the first monthly payment at the same time you fax your ERS documentation, we will discontinue withholding your Medicare claim payments. Please include a statement providing the check number, check amount, and date you mailed the first monthly payment. If you do not submit the first payment, a 30% withhold shall be initiated.
Please send your payment with a copy of this instruction to:
Medicare Part B - Debt Recovery
P.O. Box 44141
Jacksonville, FL 32231-4141
P.O. Box 44141
Jacksonville, FL 32231-4141
