Information Collection

Beneficiary Client Form

IC 193277 under ICR 201808-0985-002 · OMB 0985-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0040 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Beneficiary Client Form	Form
1 Beneficiary Client Form BCF form.pdf	Form

IC Title:

Beneficiary Client Form

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Beneficiary Client Form	BCF form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: State Health Insurance Assistance Program (SHIP) National Performance Report (SHIP-NPR)

FR Citation: 72 FR 12

Number of Respondents: 11,435

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	Previously Approved
Annual Number of Responses for this IC	3,602,025	2,025	-2,025	3,602,025
Annual IC Time Burden (Hours)	209,988	-108,012	0	318,000
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.