Private Written Agreement Year 2_3_4

Early Retiree Reinsurance Program

Documents and Forms

Document Name Document Type
0938-1087 Revised_Instrument Collection Instructions.docx Instruction
CMS-10321 Revised ERRP Collection Instrument 0938-1087 Revised ERRP Collection Instrument-1.docx Form

Information Collection (IC) Details

IC Title:	Private Written Agreement Year 2_3_4	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.35(b)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			0938-1087 Revised_Instrument Collection Instructions.docx		Yes	No	Fillable Fileable
Form	CMS-10321	Revised ERRP Collection Instrument	0938-1087 Revised ERRP Collection Instrument-1.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 764	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-764	764
Annual IC Time Burden (Hours)	-764	764
Annual IC Cost Burden (Dollars)	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.