Information Collection

PACE State Plan Option Preprint (CMS-10227)

IC 181912 under ICR 200709-0938-001 · OMB 0938-1027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1027 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10227 PACE State Plan Option Preprint (CMS-10227) Form
SMDL-11-09-00.tif Instruction
CMS-10227 PACE State Plan Option Preprint CMS-10227 SPA PACE PREPRINT.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PACE State Plan Option Preprint (CMS-10227)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	CMS-10227	PACE State Plan Option Preprint	CMS-10227 SPA PACE PREPRINT.doc		No	No	Fillable Printable
Instruction			SMDL-11-09-00.tif		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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