SMP Individual Interaction-Basic

State Health Insurance Assistance Program (SHIP) Client Contact Forms

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 9 SMP Individual Interaction-Basic Form and Instruction
9 SMP Individual Interaction Basic Interaction Form 0040 (9) SMP SIRS Individual Interaction Basic Interaction Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	SMP Individual Interaction-Basic	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 and Instruction	9	SMP Individual Interaction Basic Interaction Form	0040 (9) SMP SIRS Individual Interaction Basic Interaction Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,935	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	284,335	284,335
Annual IC Time Burden (Hours)	23,695	23,695
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.