Information Collection

Administrative Requirements for Section 6071 of the DRA (CMS-10249)

IC 186838 under ICR 201504-0938-001 · OMB 0938-1053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1053 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10249 Administrative Requirements for Section 6071 of the DRA (CMS-10249)	Form
File_Layout_for_MFP_Finders_File - 11.26.14.pdf	Instruction
File_Layout_for_MFP_Program_Participation_Data_File - 11.26.14.pdf	Instruction
2011_1st_Period_Test_Progress_Rpt.pdf	Instruction
File_Layout_for_MFP_Services_File - 11.26.14.pdf	Instruction
CMS-10249 Semi-Annual Report (Screen Shots) MFP 2014 Semi-Annual Report Screen Shots 11.26.14.docx	Form
CMS-10249 Money Follows the Person Quality of Life Survey MFP_QoL_Final_version_English.pdf	Form and Instruction
CMS-64.9i Expenditures Appendix F 508 comp 12.08.14.pdf	Form
Crosswalk - Financial Forms 12.08.14.doc Crosswalk - Financial Forms	IC Document
Crosswalk - Semi-Annual Report 12.08.14.doc Crosswalk - Semi-Annual Report	IC Document

IC Title:

Administrative Requirements for Section 6071 of the DRA (CMS-10249)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10249	Semi-Annual Report (Screen Shots)	MFP 2014 Semi-Annual Report Screen Shots 11.26.14.docx	Yes	Yes	Fillable Fileable
Instruction			File_Layout_for_MFP_Finders_File - 11.26.14.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10249	Money Follows the Person Quality of Life Survey	MFP_QoL_Final_version_English.pdf	Yes	No	Fillable Printable
Instruction			File_Layout_for_MFP_Program_Participation_Data_File - 11.26.14.pdf	Yes	Yes	Fillable Printable
Instruction			2011_1st_Period_Test_Progress_Rpt.pdf	Yes	Yes	Fillable Printable
Instruction			File_Layout_for_MFP_Services_File - 11.26.14.pdf	Yes	Yes	Fillable Printable
Form	CMS-64.9i	Expenditures	Appendix F 508 comp 12.08.14.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45

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
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	28,575	0	-77,694	106,269
Annual IC Time Burden (Hours)	14,220	893	-25,731	39,058
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Financial Forms	Crosswalk - Financial Forms 12.08.14.doc	04/03/2015
Crosswalk - Semi-Annual Report	Crosswalk - Semi-Annual Report 12.08.14.doc	04/03/2015

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