Information Collection

GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2

IC 229686 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⚠️ Notice: This information collection may be referencing outdated material.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 #27 GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2	Form and Instruction
CMS-10398 #27 Part 2 of Modified Adjusted Gross Income (MAGI) Conversi 27 - Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.docx	Form and Instruction
27 - Final Supporting Statement MAGI Conversion Plan II.docx #27 - Supporting Statement	IC Document

IC Title:

GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2

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 #27	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan	27 - Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	56	56
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#27 - Supporting Statement	27 - Final Supporting Statement MAGI Conversion Plan II.docx	01/09/2018

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