Information Collection

Appendix A - Template for 2020 Premium Credits

IC 243085 under ICR 202008-0938-004 · OMB 0938-1381.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.