Appendix A - Template for 2020 Premium Credits

Collection of Premium Credit Adjustment Data Related to COVID-19 Emergency (CMS-10751)

Documents and Forms

Document Name Document Type
Form CMS-10751 Appendix A - Template for 2020 Premium Credits Form
CMS-10751 Appendix A - Template for 2020 Premium Credits CMS-10751 - Premium Credit Instrument - OMB - Final.docx Form

Information Collection (IC) Details

IC Title:	Appendix A - Template for 2020 Premium Credits	Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10751	Appendix A - Template for 2020 Premium Credits	CMS-10751 - Premium Credit Instrument - OMB - Final.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	175	175
Annual IC Time Burden (Hours)	175	175
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.