Children's Health Insurance Program (CHIP) Report on Payables and Receivables

Forms and Documents

Document Name	Status
Form CMS-10180 Children's Health Insurance Program (CHIP) Report on Payables and Receivables Form	Modified
CMS-10180 Crosswalk for Revisions.doc Supplementary Document	2013-05-01
CMS-10180 Supporting Statement.doc Supporting Statement A	2013-05-01

IC Document Collections

IC ID	Document Title	Status
43677	Children's Health Insurance Program (CHIP) Report on Payables and Receivables Form	Modified

ICR Details

OMB Control No: 0938-0988	ICR Reference No: 201305-0938-004
Status: Historical Inactive	Previous ICR Reference No: 200910-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: 19440
Title: Children's Health Insurance Program (CHIP) Report on Payables and Receivables
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted	Conclusion Date: 06/07/2013
	Date Received in OIRA: 05/08/2013
Terms of Clearance: The information in supporting statement A (see A 15) must match the submitted request. In this case the supporting statement indicates no change in burden when there clearly has been an addition to the form resulting in an increase in burden.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Chief Financial Officers Act of 1990, as amended by the Government Management and Reform Act of 1994, requires government agencies to produce auditable financial statements. Form CMS-10180 will collect accounting data from the States on Payables and Receivables.

---

Authorizing Statute(s): PL: Pub.L. 101 - 576 3515 Name of Law: Chief Financial Officers Act of 1990
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 24752	04/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 68785	11/16/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Children's Health Insurance Program (CHIP) Report on Payables and Receivables	CMS-10180	CMS-10180

---

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The increase in burden occurred because of an additional line item on the survey that wasn't there previously.

---

Annual Cost to Federal Government: $5,132

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/08/2013

---