Information Collection

1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50

IC 8781 under ICR 200801-0938-008 · OMB 0938-0933.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0933 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10120 1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50	Form and Instruction
CMS-10120 1932 State Plan Amendment Template CMS-10120 SPA-051004.doc	Form and Instruction

IC Title:

1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	CMS-10120	1932 State Plan Amendment Template	CMS-10120 SPA-051004.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.