Information Collection

Demonstration Project For Calculating Adjusted Average Per Capita Costs

IC 112854 under ICR 198204-0938-017 · OMB 0938-0092.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

DEMONSTRATION PROJECT FOR CALCULATING ADJUSTED AVERAGE PER CAPITA COSTS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-123	No	No
Form	L-123, 123A	No	No
Form	L-123A	No	No
Form	123L	No	No
Form	123T	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 450

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	450	100	350
Annual IC Time Burden (Hours)	150	33	117
Annual IC Cost Burden (Dollars)	0	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.