Information Collection

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

IC 7840 under ICR 200510-0938-001 · OMB 0938-0086.

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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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	125,000	125,000
Annual IC Time Burden (Hours)	62,500	62,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Title	Document	Date Uploaded

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