Information Collection

State Plan Certification Form And State Health Plan Budget

IC 112199 under ICR 197608-0937-001 · OMB 0937-0009.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

STATE PLAN CERTIFICATION FORM AND STATE HEALTH PLAN BUDGET

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5153-1				No	No
Form	5153-2				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 335

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	335	335
Annual IC Time Burden (Hours)	8,200	8,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.