Start-up & Solvency Loan Application

Consumer Operated and Oriented Plan [CO-OP] Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1139 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10392 Start-up & Solvency Loan Application Form and Instruction
CMS-10392 CO-OP FOA CMS-10392.CO-OP FOA (12-9-11).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Start-up & Solvency Loan 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: 45 CFR 156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10392	CO-OP FOA	CMS-10392.CO-OP FOA (12-9-11).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27	Number of Respondents for Small Entity: 27

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27	8	19
Annual IC Time Burden (Hours)	13,932	4,128	9,804
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.