Information Collection

Demonstration Project For Calculating Adjusted Average Per Capita Costs

IC 166159 under ICR 198305-0938-010 · OMB 0938-0092.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0092 can be found here:

Documents and Forms

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Information Collection (IC) Details

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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:

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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,500	1,050	450
Annual IC Time Burden (Hours)	750	600	150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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