Information Collection

Reconciliation of State Invoice and Prior Quarter Adjustment Statement

IC 8258 under ICR 199603-0938-003 · OMB 0938-0676.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0676 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Reconciliation of State Invoice and Prior Quarter Adjustment Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-304				No	No
Form	HCFA-304A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 520	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	2,080	152	1,928
Annual IC Time Burden (Hours)	170,560	53,664	116,896
Annual IC Cost Burden (Dollars)	1,705,600,000	1,705,600,000	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.