Information Collection

GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template

IC 241971 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⚠️ Notice: This information collection may be referencing outdated material.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-10120 1932(a) State Plan Amendment Template GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template	Form
CMS-10120 1932(a) State Plan Amendment Template 1932a State Plan Preprint- 508 approved 2020 version 2.pdf	Form
63 - Generic Supporting Statement (2020 version 3).docx Generic Supporting Statement	IC Document

IC Title:

GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10120	1932(a) State Plan Amendment Template	1932a State Plan Preprint- 508 approved 2020 version 2.pdf		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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	63 - Generic Supporting Statement (2020 version 3).docx	05/26/2020

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