Information Collection

State Plan Under Title XIX of the Social Security Act (Base plan pages)

IC 7877 under ICR 201203-0938-014 · OMB 0938-0193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0193 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-179 State Plan Under Title XIX of the Social Security Act (Base plan pages)	Form and Instruction
Exhibit A.doc	Other-Exhibt A
Exhibit A1.doc	Other-Exhibit A1
Exhibit AA.doc	Other-Exhibit AA
Exhibit AB.doc	Other-Exhibit AB
Exhibit AC.doc	Other-Exhibit AC
Exhibit AD.doc	Other-Exhibit AD
Exhibit AE.doc	Other-Exhibit AE
Exhibit AF.doc	Other-Exhibit AF
Exhibit AG.doc	Other-Exhibit AG
Exhibit D and E.doc	Other-Exhibit D and E
Exhibit F and G.doc	Other-Exhibit F and G
Exhibit H and J.doc	Other-Exhibit H and J
Exhibit N.doc	Other-Exhibit N
Exhibit O.doc	Other-Exhibit O
Exhibit P.doc	Other-Exhibit P
Exhibit Y.doc	Other-Exhibit Y
CLEAN DP Revised 03-12-12 FMG rev4 19 b - DP 07-17-08 (6).doc	Other-FMG
Exhibits R S T U.doc	Other-Exhibit R S T U
CMS-179 Transmittal and Notice of Approval of State Plan Materia CMS-179 Transmittal Notice [2009 package].pdf	Form and Instruction
CMS-179 Exhibit 1 [rev CMCS 03-27-12 and OSORA 03-29-12].docx CMS-179 Exhibit 1 [rev CMCS 03-27-12 and OSORA 03-29-12]	IC Document
Crosswalk for 4.19 B.doc Crosswalk for 4	IC Document

IC Title:

State Plan Under Title XIX of the Social Security Act (Base plan pages)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-179	Transmittal and Notice of Approval of State Plan Material	CMS-179 Transmittal Notice [2009 package].pdf	Yes	No	Fillable Printable
Other-Exhibit AB			Exhibit AB.doc	Yes	Yes	Fillable Fileable
Other-Exhibit A1			Exhibit A1.doc	Yes	Yes	Fillable Fileable
Other-Exhibit AA			Exhibit AA.doc	Yes	Yes	Fillable Fileable
Other-Exhibt A			Exhibit A.doc	Yes	Yes	Fillable Fileable
Other-Exhibit AC			Exhibit AC.doc	Yes	Yes	Fillable Fileable
Other-Exhibit AD			Exhibit AD.doc	Yes	Yes	Fillable Fileable
Other-Exhibit AE			Exhibit AE.doc	Yes	Yes	Fillable Fileable
Other-Exhibit AF			Exhibit AF.doc	Yes	Yes	Fillable Fileable
Other-Exhibit AG			Exhibit AG.doc	Yes	Yes	Fillable Fileable
Other-Exhibit D and E			Exhibit D and E.doc	Yes	Yes	Fillable Fileable
Other-Exhibit F and G			Exhibit F and G.doc	Yes	Yes	Fillable Fileable
Other-Exhibit H and J			Exhibit H and J.doc	Yes	Yes	Fillable Fileable
Other-Exhibit N			Exhibit N.doc	Yes	Yes	Fillable Fileable
Other-Exhibit O			Exhibit O.doc	Yes	Yes	Fillable Fileable
Other-Exhibit P			Exhibit P.doc	Yes	Yes	Fillable Fileable
Other-Exhibit Y			Exhibit Y.doc	Yes	Yes	Fillable Fileable
Other-FMG			CLEAN DP Revised 03-12-12 FMG rev4 19 b - DP 07-17-08 (6).doc	Yes	Yes	Fillable Fileable
Other-Exhibit R S T U			Exhibits R S T U.doc	Yes	Yes	Fillable Fileable

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,120	0	-3,561	4,681
Annual IC Time Burden (Hours)	22,400	21	13,108	9,271
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-179 Exhibit 1 [rev CMCS 03-27-12 and OSORA 03-29-12]	CMS-179 Exhibit 1 [rev CMCS 03-27-12 and OSORA 03-29-12].docx	03/29/2012
Crosswalk for 4	Crosswalk for 4.19 B.doc	03/29/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.