Information Collection

Change of Ownership

IC 244400 under ICR 202011-0938-001 · OMB 0938-1408.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10744.Change o Change of Ownership	Form and Instruction
CMS-10744.Change o CMS-10744.Change of Ownership Form (30-day notice) CMS-10744.Change of Ownership Form (30-day notice).pdf	Form and Instruction

IC Title:

Change of Ownership

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.422(d)

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 and Instruction	CMS-10744.Change of Ownership Form (30-day notice)	CMS-10744.Change of Ownership Form (30-day notice)	CMS-10744.Change of Ownership Form (30-day notice).pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	7	7
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.