Information Collection

State Report on the Transitional Medical Assistance Section 5004 of ARRA

IC 191135 under ICR 201305-0938-021 · OMB 0938-1073.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1073 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10295 State Report on the Transitional Medical Assistance Section 5004 of ARRA	Form and Instruction
CMS-10295 State Report on the Transitional Medical Assistance Sect ARRA-Sec-5004-State-Report-3.xlsx	Form and Instruction
Disclosure_Statement_for_Section_5004.DOC Disclosure Statement	IC Document

IC Title:

State Report on the Transitional Medical Assistance Section 5004 of ARRA

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 435.112

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-10295	State Report on the Transitional Medical Assistance Section 5004 of ARRA	ARRA-Sec-5004-State-Report-3.xlsx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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
	Requested	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	200	0	200
Annual IC Time Burden (Hours)	400	-200	600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Disclosure Statement	Disclosure_Statement_for_Section_5004.DOC	05/24/2013

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