The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

ICR 200107-0938-013

OMB: 0938-0270

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0270 200107-0938-013
Historical Active 199807-0938-002
HHS/CMS
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
Extension without change of a currently approved collection   No
Regular
Approved without change 09/24/2001
Retrieve Notice of Action (NOA) 07/26/2001
  Inventory as of this Action Requested Previously Approved
09/30/2004 09/30/2004 09/30/2001
500 0 500
1,000 0 1,000
0 0 0

This form is used to collect financial information which is needed to evaluate requests from physicians/suppliers to pay indebtedness under an extended repayment schedule, or to compromise a debt less than the full amount.

None
None


No

1
IC Title Form No. Form Name
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 HCFA-379

  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 500 500 0 0 0 0
Annual Time Burden (Hours) 1,000 1,000 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.
07/26/2001


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