Form CMS-10751 Appendix A - Template for 2020 Premium Credits

OMB Control Number: 0938-NEW

Expiration Date: XXXX

Appendix A - Template for 2020 Premium Credits Associated with the

COVID-19 Public Health Emergency

HIOS	Line of Business (LOB)	Organization Name	HIOS Contact Name	HIOS Contact Phone Number	HIOS Contact Email	Approval from State (Y/N)	Fixed Percentage	Credit Start Date	Credit End Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-NEW.  The time required to complete this information collection is estimated to average 1 hour per response, including the time to gather the data needed and complete and submit the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 

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