Information Collection

Income and Eligibility Verification System Reporting and Supporting Regs.

IC 8090 under ICR 201506-0938-014 · OMB 0938-0467.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0467 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification System (IEVS) - PARIS SPA Template Income and Eligibility Verification System Reporting and Supporting Regs.	Form
CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification S CMS-R-74 - IEVS-PARIS SPA Template.pdf	Form

IC Title:

Income and Eligibility Verification System Reporting and Supporting Regs.

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 435.910 42 CFR 431.306 42 CFR 435.940-435.960 42 CFR 435.920 42 CFR 431.17

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-R-74				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Previously Approved
Annual Number of Responses for this IC	3,245	3,174	71
Annual IC Time Burden (Hours)	1,130	-133,735	134,865
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.

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