Application

Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10371 Application Form and Instruction
CMS-10371 Revised FOA FOA - IE-HBE-11-004.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10371	Revised FOA	FOA - IE-HBE-11-004.pdf		Yes	No	Fillable Fileable

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	22,560	22,560
Annual IC Cost Burden (Dollars)	28,081	28,081

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.