State Flexibility Grants Activities

Information Collection Requirements Contained in the State Flexibility to Stabilize the Market Grant Program (CMS-10657)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1366 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10657 State Flexibility Grants Activities Form and Instruction
CMS-10657 State Flexibility Grant Annual Report Template CMS-10657 - State Flexibility Grant Annual Report Template.pdf Form and Instruction
CMS-10657 State Flexibility Grant Quarterly Report Template CMS-10657 - State Flexibility Grant Quarterly Report Template.pdf Form and Instruction
CMS-10657 State Flexibility Grant Final Report Template CMS-10657 - State Flexibility Grant Final Report Template.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	State Flexibility Grants Activities	Agency IC Tracking Number:	10657

Is this a Common Form? No		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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10657	State Flexibility Grant Annual Report Template	CMS-10657 - State Flexibility Grant Annual Report Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10657	State Flexibility Grant Quarterly Report Template	CMS-10657 - State Flexibility Grant Quarterly Report Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10657	State Flexibility Grant Final Report Template	CMS-10657 - State Flexibility Grant Final Report Template.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	155	155
Annual IC Time Burden (Hours)	2,108	2,108
Annual IC Cost Burden (Dollars)	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.