Information Collection

Administrative Requirements for Section 6071 of the DRA (CMS-10249)

IC 186838 under ICR 201807-0938-002 · OMB 0938-1053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1053 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10249 Administrative Requirements for Section 6071 of the DRA (CMS-10249) Form
MFP_Semi-Annual_Progress_Rpt_Help_File (2018_1).pdf Instruction
CMS-10249 MFP Semi-Annual Report MFP_Final_06SEP17 (2018_1).pdf Form
CMS-10249 Annual Financial Forms for Existing Grantees Financial_Forms_for_Existing_Grantees_12-8-14 (2018_1).pdf Form and Instruction
CMS-10249 MFP Financial Reporting Forms ABCD MFP_Financial_Reporting_FormsABCD 09-06-2018.xls Form
CMS-10249 Additional Benchmarks – Addendum to the MFP Semi-Annual Additional_Benchmarks_Addendum_Final (2018_1 ).pdf Form and Instruction
CMS-64.9i, -64.9pi Quarterly Expenditures Appendix F 508 comp 12.08.14 (2018_1).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Administrative Requirements for Section 6071 of the DRA (CMS-10249)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10249	MFP Semi-Annual Report	MFP_Final_06SEP17 (2018_1).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10249	Annual Financial Forms for Existing Grantees	Financial_Forms_for_Existing_Grantees_12-8-14 (2018_1).pdf	Yes	Yes	Fillable Printable
Form	CMS-10249	MFP Financial Reporting Forms ABCD	MFP_Financial_Reporting_FormsABCD 09-06-2018.xls	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10249	Additional Benchmarks â Addendum to the MFP Semi-Annual Progress Report	Additional_Benchmarks_Addendum_Final (2018_1 ).pdf	Yes	Yes	Fillable Printable
Instruction			MFP_Semi-Annual_Progress_Rpt_Help_File (2018_1).pdf	Yes	Yes	Fillable Printable
Form	CMS-64.9i, -64.9pi, -64.10i, and -64.910pi,	Quarterly Expenditures	Appendix F 508 comp 12.08.14 (2018_1).pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 44	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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	352	-8	-28,215	28,575
Annual IC Time Burden (Hours)	3,168	408	-11,460	14,220
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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