Information Collection

Premium Payment (2012)

IC 193404 under ICR 201104-0938-001 · OMB 0938-1095.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1095 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10334 Premium Payment (2012)	Form and Instruction
CMS-10334 PreExistingConditionPlan_EnrollmentForm_Spanish_508 PreExistingConditionPlan_EnrollmentForm_Spanish_508.pdf	Form and Instruction
CMS-10334 CMS-10334.DRAFT Federal fallback enrollment form CMS-10334.DRAFT Federal fallback enrollment form.pdf	Form and Instruction

IC Title:

Premium Payment (2012)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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-10334	PreExistingConditionPlan_EnrollmentForm_Spanish_508	PreExistingConditionPlan_EnrollmentForm_Spanish_508.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10334	CMS-10334.DRAFT Federal fallback enrollment form	CMS-10334.DRAFT Federal fallback enrollment form.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 33,333

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	33,333	33,333
Annual IC Time Burden (Hours)	5,333	5,333
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.