Information Collection

Application

IC 195986 under ICR 201111-0938-011 · OMB 0938-1119.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10371 FOA Application	Form and Instruction
0938-1119 - FOA - Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges.pdf	Instruction
CMS-10371 FOA 0938-1119.Amended Exchange Establishment FOA.docx	Form and Instruction

IC Title:

Application

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
Instruction					Yes	Yes	Paper Only
Form and Instruction	CMS-10371				Yes	No	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	50	50
Annual IC Time Burden (Hours)	28,200	28,200
Annual IC Cost Burden (Dollars)	42,770	42,770

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].