Information Collection

Exemption Applications - Eligibility for Exemptions

IC 205753 under ICR 201311-0938-010 · OMB 0938-1190.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1190 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10466 Exemption Applications - Eligibility for Exemptions	Form and Instruction
CMS-10466 Application for Exemptions Religious Sects or Divisions Application for Exemption for religious sect_121813-508-final.pdf	Form and Instruction
CMS-10466 Application Exemption - Hardships Application_Exemption_Hardship-12192013-508.pdf	Form and Instruction
CMS-10466 Application Exemptions - Incarerated Application_Exemption_Incarcerated_12-18-2013_508_final.pdf	Form and Instruction
CMS-10466 Application Exemptions Shared Responsibility for FFM's Application_Exemption_SharedResponsibility_FFM-12-18-13 508 final 2103 p....pdf	Form and Instruction
CMS-10466 Exemption Application - Shared Responsibility SBM's Application_Exemption_SharedResponsibility_SBM-121813 pre508 final.pdf	Form and Instruction
CMS-10466 Exemption Application - Health Care Sharing Ministries Application_Exemption_SharingMinistry-12-18-2013 508 final.pdf	Form and Instruction
CMS-10466 Exemption Application - Federally Recognized Tribes Application_Exemption_Tribe-121813-pre508 final.pdf	Form and Instruction

IC Title:

Exemption Applications - Eligibility for Exemptions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.610 45 CFR 155.615 45 CFR 155.620 45 CFR 155.625

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-10466	Application Exemption - Hardships	Application_Exemption_Hardship-12192013-508.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Application for Exemptions Religious Sects or Divisions	Application for Exemption for religious sect_121813-508-final.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Application Exemptions - Incarerated	Application_Exemption_Incarcerated_12-18-2013_508_final.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Application Exemptions Shared Responsibility for FFM's	Application_Exemption_SharedResponsibility_FFM-12-18-13 508 final 2103 p....pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Exemption Application - Shared Responsibility SBM's	Application_Exemption_SharedResponsibility_SBM-121813 pre508 final.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Exemption Application - Health Care Sharing Ministries	Application_Exemption_SharingMinistry-12-18-2013 508 final.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Exemption Application - Federally Recognized Tribes	Application_Exemption_Tribe-121813-pre508 final.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12,000,000	12,000,000
Annual IC Time Burden (Hours)	3,240,000	3,240,000
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.