Information Collection

MAGI Conversion Plan (Information Collection #14 )

IC 206399 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#14) MAGI Conversion Plan (Information Collection #14 )	Form and Instruction
CMS-10398 (#14) 14 MAGI Conversion Plan MAGI Income Conversion Plan revised_4_3 [rev 4-5-13 by OSORA PRA].docx	Form and Instruction
MAGI Conversion Plan Supporting Statement.docx MAGI Conversion Plan Supporting Statement	IC Document

IC Title:

MAGI Conversion Plan (Information Collection #14 )

Agency IC Tracking Number:

IC Status: New

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-10398 (#14)	14 MAGI Conversion Plan	MAGI Income Conversion Plan revised_4_3 [rev 4-5-13 by OSORA PRA].docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	56	0	0	0	0	0
Annual IC Time Burden (Hours)	1,120	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MAGI Conversion Plan Supporting Statement	MAGI Conversion Plan Supporting Statement.docx	04/05/2013

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