Information Collection

State Balancing Incentive Payments Program (BIPP) Application

IC 199182 under ICR 201111-0938-012 · OMB 0938-1145.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10411 State Balancing Incentive Payments Program (BIPP) Application State Balancing Incentive Payments Program (BIPP) Application	Form and Instruction
CMS-10411 State Balancing Incentive Payments Program (BIPP) Applic BIPP App_Clean_083111 [rev 11-29-11].doc	Form and Instruction

IC Title:

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-10411				Yes	Yes	Printable Only

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	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
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.

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