CMS-10398 (#36) DOMA CHIP Eligibility SPA Template

CHIP Eligibility

State: _____________ OMB Control Number: 0938-1148

Transmittal Number: _____________ OMB Expiration Date: xx/xx/xxxx

Same-Sex Marriage Policy CSXX

2102(b)(1)(B)(v) of the SSA

• With respect to individuals or an individual’s family for whom the state must complete a determination of income based on MAGI, the state:

• Recognizes same-sex couples as spouses, if they are legally married under the laws of the state, territory, or foreign jurisdiction in which the marriage was celebrated.

• Does not recognize same-sex couples as spouses, even if they were legally married in a state, territory, or foreign jurisdiction that recognizes same-sex marriages.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850.