CONTRACTORS' INFORMATION COLLECTIONS -- EXTENDED REPAYMENT SCHEDULE

ICR 198111-0938-003

OMB: 0938-0201

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0201 198111-0938-003
Historical Active
HHS/CMS
CONTRACTORS' INFORMATION COLLECTIONS -- EXTENDED REPAYMENT SCHEDULE
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/19/1981
Retrieve Notice of Action (NOA) 11/19/1981
  Inventory as of this Action Requested Previously Approved
04/30/1983 04/30/1983
5,000 0 0
25,000 0 0
0 0 0

FORMS ARE USED BY INTERMEDIARIES TO RECOVER AND RETURN TO THE MEDICARE TRUST FUND OVERPAYMENTS MADE TO PROVIDERS. PROVIDERS REQUESTING EXTENDED REPAYMENT SCHEDULES ARE REQUESTED TO SUBMIT A VARIETY OF FINANCIAL STATEMENTS DOCUMENTING THEIR CURRENT FINANCIAL STATUS. IT IS THEN DETERMINED IF AN EXTENDED REPAYMENT SCHEDULE WILL BE GRANTED.

None
None


No

1
IC Title Form No. Form Name
CONTRACTORS' INFORMATION COLLECTIONS -- EXTENDED REPAYMENT SCHEDULE 9004

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,000 0 0 0 5,000 0
Annual Time Burden (Hours) 25,000 0 0 0 25,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/19/1981


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