Information Collection

SHOP - Employer

IC 205691 under ICR 201302-0938-003 · OMB 0938-1193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1193 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10439 SHOP - Employer	Form and Instruction
CMS-10439 Appendix A SHOP Employer Questionnaire CMS-10439.Appendix_A (SHOP- Employer)-5-9-13.docx	Form and Instruction
CMS-10439 Appendix B SHOP Employer Application SHOP ApplicationforEmployers.052313-508.pdf	Form and Instruction

IC Title:

SHOP - Employer

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 155.725 45 CFR 155.730 45 CFR 155.410

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-10439	Appendix A SHOP Employer Questionnaire	CMS-10439.Appendix_A (SHOP- Employer)-5-9-13.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10439	Appendix B SHOP Employer Application	SHOP ApplicationforEmployers.052313-508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 177,777

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: 90 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	177,777	177,777
Annual IC Time Burden (Hours)	36,089	36,089
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.