OWNERSHIP AND FINANCIAL INTEREST DISCLOSURE STATEMENT

ICR 198303-0938-004

OMB: 0938-0086

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
112826 Migrated
ICR Details
0938-0086 198303-0938-004
Historical Active 197902-0938-002
HHS/CMS
OWNERSHIP AND FINANCIAL INTEREST DISCLOSURE STATEMENT
Extension without change of a currently approved collection   No
Regular
Approved without change 05/26/1983
Retrieve Notice of Action (NOA) 03/25/1983
  Inventory as of this Action Requested Previously Approved
05/31/1984 05/31/1984 03/31/1983
30,000 0 30,000
30,000 0 30,000
0 0 0

PUBLIC LAW 95-142 PROVIDES THAT THE INFORMATION ELICITED BY THE HCFA-1513 WILL BE USED BY THE STATE AGENCIES AND HHS/HCFA REGIONAL OFFICES IN MAKING DETERMINATION OF ELIGIBILITY FOR PARTICIPATION IN TH TITLES XVIII, XIX, V AND XX PROGRAMS AS WELL AS FOR GRANTS UNDER TITLE V AND XX.

None
None


No

1
IC Title Form No. Form Name
OWNERSHIP AND FINANCIAL INTEREST DISCLOSURE STATEMENT HCFA-1513

  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 30,000 30,000 0 0 0 0
Annual Time Burden (Hours) 30,000 30,000 0 0 0 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.
03/25/1983


© 2024 OMB.report | Privacy Policy