Information Collection

Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients

IC 198653 under ICR 201504-0938-015 · OMB 0938-1139.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10392 Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	Form and Instruction
CMS-10392 Reporting Templates CMS-10392.CO-OP Reporting Template.docx	Form and Instruction
CMS-10392 CO-OP FOA CMS-10392_CO-OP_FOA_(final).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156

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-10392	Reporting Templates	CMS-10392.CO-OP Reporting Template.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10392	CO-OP FOA	CMS-10392_CO-OP_FOA_(final).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

Number of Respondents for Small Entity: 23

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	368	92	276
Annual IC Time Burden (Hours)	9,568	4,048	5,520
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.