Information Collection

GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment

IC 229616 under ICR 201712-0938-019 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #21 GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment	Form and Instruction
21 - FMAP Claiming SPA Instructions.docx	Instruction
CMS-10398 #21 SPA Attachments: Threshold Methodology for Identificatio 21 - FMAP Claiming SPA 9-16-13-Attachments.docx	Form and Instruction
21 - FMAP Claiming SPA Supporting Statement.docx #21 - Supporting Statement	IC Document

IC Title:

GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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-10398 #21	SPA Attachments: Threshold Methodology for Identification of Applicable FMAP Rates	21 - FMAP Claiming SPA 9-16-13-Attachments.docx		Yes	Yes	Fillable Fileable
Instruction			21 - FMAP Claiming SPA Instructions.docx		Yes	Yes	Printable Only

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#21 - Supporting Statement	21 - FMAP Claiming SPA Supporting Statement.docx	12/29/2017

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