Information Collection

Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)

IC 191135 under ICR 201004-0938-011 · OMB 0938-1073.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1073 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10295 State Report on the Use of Increase FMAP Section 5001 of ARRA Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)	Form and Instruction
Form CMS-10295 State Report on the Transitional Medical Assistance Section 5004 of ARRA Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)	Form and Instruction
CMS-10295 State Report on the Use of Increase FMAP Section 5001 of 08-20-09 ARRA-Sec-5001-State-Report-3.pdf	Form and Instruction
CMS-10295 State Report on the Transitional Medical Assistance Sect 08-20-09 ARRA-Sec-5004-State-Report-3.pdf	Form and Instruction
Disclosure Statement for Section 5001.DOC Disclosure Statement for Section 5001	IC Document
Disclosure Statement for Section 5004.DOC Disclosure Statement for Section 5004	IC Document

IC Title:

Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-10295				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10295				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	200	200
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Disclosure Statement for Section 5001		09/16/2009
Disclosure Statement for Section 5004		09/16/2009

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

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