Exemption Applications - Eligibility for Exemptions

Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10466 Exemption Applications - Eligibility for Exemptions 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 Application Exemption - Hardships Application_Exemption_Hardship-12192013-508.pdf Form and Instruction
CMS-10466 Application for Exemption for American Indians CMS-10466 - Application Exemption Tribe NSCR 2014 508.pdf Form and Instruction
CMS-10466 Application for Exemptions Religious Sects or Divis CMS-10466 - Application for Exemption for religious sects NSCR2014 508.pdf Form and Instruction

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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	Application for Exemptions Religious Sects or Divis	CMS-10466 - Application for Exemption for religious sects NSCR2014 508.pdf	Yes	No	Fillable Printable
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 Exemption for American Indians	CMS-10466 - Application Exemption Tribe NSCR 2014 508.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 %

	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

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.