Information Collection

#14: MAGI Conversion Plan

IC 214301 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#14) #14: MAGI Conversion Plan	Form and Instruction
CMS-10398 (#14) Modified Adjusted Gross Income (MAGI) Conversion Plan MAGI Income Conversion Plan revised_4_3 [rev 4-5-13 by OSORA PRA].docx	Form and Instruction
#14 MAGI Conversion Plan Supporting Statement [Dec 2014].docx #14 Supporting Statement: MAGI Conversion Plan	IC Document

IC Title:

#14: MAGI Conversion Plan

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10398 (#14)	Modified Adjusted Gross Income (MAGI) Conversion Plan	MAGI Income Conversion Plan revised_4_3 [rev 4-5-13 by OSORA PRA].docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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 Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#14 Supporting Statement: MAGI Conversion Plan	#14 MAGI Conversion Plan Supporting Statement [Dec 2014].docx	12/22/2014

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