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

ICR 200510-0938-001

OMB: 0938-0086

Federal Form Document

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Document
Name
Status
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ICR Details
0938-0086 200510-0938-001
Historical Active 200207-0938-013
HHS/CMS
Disclosure of Ownership and Financial Control Interest Statement and Supporting Regulations Contained in 42 CFR 420.200-.206 and 455.100-.106
Extension without change of a currently approved collection   No
Regular
Approved without change 12/07/2005
Retrieve Notice of Action (NOA) 10/06/2005
  Inventory as of this Action Requested Previously Approved
12/31/2008 12/31/2008 12/31/2005
125,000 0 125,000
62,500 0 62,500
0 0 0

This information must be collected by State agencies and CMS reguional offices to determine whether providers/suppliers meet the eligibility requirements for Titles 18, 19, CLIA, and for grants under Titles V and XX. Review of ownership and control is particularly necessary to prohibit ownership and control for individuals excluded under Federal fraud statutes.

None
None


No

  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 125,000 125,000 0 0 0 0
Annual Time Burden (Hours) 62,500 62,500 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.
10/06/2005


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