Information Collection

Section 1115 Demonstration Application Template

IC 200533 under ICR 201112-0938-009 · OMB 0938-1159.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10412 Section 1115 Demonstration Application Template	Form and Instruction
CMS-10412 Section 1115 Demonstration Application Template Section 1115 Application Template [rev 12-15-11].docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-10412	Section 1115 Demonstration Application Template	Section 1115 Application Template [rev 12-15-11].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 Agency Discretion
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	448	448
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.