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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10120 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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.