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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.