STATEMENT OF REIMBURSABLE COSTS

ICR 198409-0938-019

OMB: 0938-0271

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
166227 Migrated
ICR Details
0938-0271 198409-0938-019
Historical Active 198211-0938-005
HHS/CMS
STATEMENT OF REIMBURSABLE COSTS
No material or nonsubstantive change to a currently approved collection   No
Emergency 09/28/1984
Approved with change 09/28/1984
Retrieve Notice of Action (NOA) 09/28/1984
  Inventory as of this Action Requested Previously Approved
03/31/1985 03/31/1985 03/31/1985
200 0 200
8,000 0 8,000
0 0 0

ALL TREATMENT FACILITIES PARTICIPATING IN THE ALCOHOLISM SERVICES DEMONSTRATION WILL DOCUMENT SERVICES AND COSTS ON THE STATEMENT OF REIMBURSABLE COST FORMS. THE HCFA OFFICE OF REIMBURSEMENT WILL MAKE PAYMENT ON THE BASIS OF THESE STATEMENTS.

None
None


No

1
IC Title Form No. Form Name
STATEMENT OF REIMBURSABLE COSTS HCFA-1480B

  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 200 200 0 0 0 0
Annual Time Burden (Hours) 8,000 8,000 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.
09/28/1984


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