Disclosure of Ownership and Financial Control Interest Statement and Supporting Regulations Contained in 42 CFR 420.200-.206 and 455.100-.106

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IC Title:	Disclosure of Ownership and Financial Control Interest Statement and Supporting Regulations Contained in 42 CFR 420.200-.206 and 455.100-.106	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-1513				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 125,000	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	125,000	33,000	92,000
Annual IC Time Burden (Hours)	62,500	16,500	46,000
Annual IC Cost Burden (Dollars)	0	0	0

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