The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

OMB: 0938-0270

IC ID: 7924

Information Collection (IC) Details

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The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 405.376(g) 32 CFR 902.2(g) 32 CFR 901.8(a)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-379 Financial Statement of Debtor CMS-379 REVISED - without SSN vj508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

500 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 500 0 0 0 0 500
Annual IC Time Burden (Hours) 1,000 0 0 0 0 1,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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