Information Collection

#21: FMAP Claiming State Plan Amendment

IC 214322 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⚠️ Notice: This information collection may be referencing outdated material.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 (#21) #21: FMAP Claiming State Plan Amendment	Form
FMAP Claiming SPA Instructions.docx	Instruction
CMS-10398 (#21) Threshold Methodology for Identification of Applicable F FMAP Claiming SPA 9-16-13-Attachments.docx	Form
#21 FMAP Claiming SPA Supporting Statement [Dec 2014].docx #21 Supporting Statement: FMAP Claiming State Plan Amendment	IC Document

IC Title:

#21: FMAP Claiming State Plan Amendment

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	CMS-10398 (#21)	Threshold Methodology for Identification of Applicable FMAP Rates	FMAP Claiming SPA 9-16-13-Attachments.docx		Yes	Yes	Fillable Printable
Instruction			FMAP Claiming SPA Instructions.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#21 Supporting Statement: FMAP Claiming State Plan Amendment	#21 FMAP Claiming SPA 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.