Information Collection

#36: Same Sex Marriage Policy

IC 214373 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⚠️ Notice: This information collection may be referencing outdated material.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 (#36) DOMA Medicaid Eligibility SPA Template #36: Same Sex Marriage Policy	Form
Form CMS-10398 (#36) DOMA CHIP Eligibility SPA Template #36: Same Sex Marriage Policy	Form
CMS-10398 (#36) DOMA Medicaid Eligibility SPA Template DOMA SPA Template [rev 9-11-2014 by OSORA PRA].docx	Form
CMS-10398 (#36) DOMA CHIP Eligibility SPA Template DOMA CHIP SPA Template [rev 9-11-2014 by OSORA PRA].docx	Form
#36 Same Sex Marriage [Dec 2014].docx #36 Supporting Statement: Same Sex Marriage Policy	IC Document

IC Title:

#36: Same Sex Marriage Policy

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 (#36)	DOMA Medicaid Eligibility SPA Template	DOMA SPA Template [rev 9-11-2014 by OSORA PRA].docx		Yes	Yes	Fillable Printable
Form	CMS-10398 (#36)	DOMA CHIP Eligibility SPA Template	DOMA CHIP SPA Template [rev 9-11-2014 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)	56	56
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#36 Supporting Statement: Same Sex Marriage Policy	#36 Same Sex Marriage [Dec 2014].docx	12/22/2014

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