Information Collection

(149.40) - Updating Data in the Application

IC 201223 under ICR 201202-0938-004 · OMB 0938-1087.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10321 ERRP Application (149.40) - Updating Data in the Application	Form
CMS-10321.ERRP Application Instructions (508).pdf	Instruction
CMS-10321 ERRP Application CMS-10321.ERRP Application (508).pdf	Form

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: 45 CFR 149.40

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			CMS-10321.ERRP Application Instructions (508).pdf		Yes	No	Printable Only
Form	CMS-10321	ERRP Application	CMS-10321.ERRP Application (508).pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Early Retiree Reinsurance Program

FR Citation: 75 FR 31440

Number of Respondents: 916

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	916	916
Annual IC Time Burden (Hours)	916	916
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.