Information Collection

GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services

IC 229734 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⚠️ Notice: This information collection may be referencing outdated material.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 #46 GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services	Form
CMS-10398 #46 1915(i) Template 46 - 1915(i) Final Template.docx	Form
46 - Supporting Statement 1915(i) - CLEAN.docx #46 - Supporting Statement	IC Document

IC Title:

GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services

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	CMS-10398 #46	1915(i) Template	46 - 1915(i) Final Template.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9

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	9	9
Annual IC Time Burden (Hours)	1,026	1,026
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#46 - Supporting Statement	46 - Supporting Statement 1915(i) - CLEAN.docx	01/12/2018

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