Information Collection

Administrative Requirements for Section 6071 of the DRA

IC 186838 under ICR 202107-0938-006 · OMB 0938-1053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1053 can be found here:

2024-02-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10249 Administrative Requirements for Section 6071 of the DRA	Form
Form CMS-10249 Semi-Annual Progress Report Administrative Requirements for Section 6071 of the DRA	Form
Form CMS-10249 MFP Financial Reporting Forms ABCD Administrative Requirements for Section 6071 of the DRA	Form
Form CMS-64.9i, -64.9pi Quarterly Expenditures Administrative Requirements for Section 6071 of the DRA	Form
Form CMS-10249 MFP_Budget_Workbook Administrative Requirements for Section 6071 of the DRA	Form and Instruction
Form CMS-10249 Maintenance of Effort (MOE) Form Administrative Requirements for Section 6071 of the DRA	Form and Instruction
MFP_Semi-Annual_Report_Help_File.pdf	Instruction
MFP_Semi-Annual_Report_Help_File.pdf	Instruction
CMS-10249 Semi-Annual Progress Report MFP_ Semi-Annual_Report Final.pdf	Form
CMS-10249 Semi-Annual Progress Report MFP_ Semi-Annual_Report Final.pdf	Form
CMS-10249 MFP Financial Reporting Forms ABCD MFP_Financial_Reporting_FormsABCD.pdf	Form
CMS-10249 MFP Financial Reporting Forms ABCD MFP_Financial_Reporting_FormsABCD.pdf	Form
CMS-10249 Additional Benchmarks – Addendum to the MFP Semi-Annual Additional Benchmarks – Addendum to the MFP Semi-Annual Progress Report.pdf	Form and Instruction
CMS-10249 Additional Benchmarks – Addendum to the MFP Semi-Annual Additional Benchmarks – Addendum to the MFP Semi-Annual Progress Report.pdf	Form and Instruction
CMS-64.9i, -64.9pi Quarterly Expenditures CMS 64i Expenditure Forms.pdf	Form
CMS-64.9i, -64.9pi Quarterly Expenditures CMS 64i Expenditure Forms.pdf	Form
CMS-10249 MFP_Budget_Workbook MFP_Budget_Workbook.pdf	Form and Instruction
CMS-10249 MFP_Budget_Workbook MFP_Budget_Workbook.pdf	Form and Instruction
CMS-10249 Maintenance of Effort (MOE) Form MFP_MOE_Form.pdf	Form and Instruction
CMS-10249 Maintenance of Effort (MOE) Form MFP_MOE_Form.pdf	Form and Instruction
MFP Semi-Annual Report Final Crosswalk.pdf Crosswalk: Semi-Annual Progress Report	IC Document
MFP Semi-Annual Report Final Crosswalk.pdf Crosswalk: Semi-Annual Progress Report	IC Document
Additional Benchmarks – Addendum to the MFP Semi-Annual Progress Report Crosswalk.pdf Crosswalk: Additional Benchmarks – Addendum to the MFP Semi-Annual Progress Report	IC Document
Additional Benchmarks – Addendum to the MFP Semi-Annual Progress Report Crosswalk.pdf Crosswalk: Additional Benchmarks – Addendum to the MFP Semi-Annual Progress Report	IC Document
MFP Semi-Annual Report Help File Crosswalk.pdf Crosswalk: MFP_Semi-Annual_Help_File	IC Document
MFP Semi-Annual Report Help File Crosswalk.pdf Crosswalk: MFP_Semi-Annual_Help_File	IC Document
MFP Budget Workbook Crosswalk.pdf Crosswalk: MFP_Budget_Workbook	IC Document
MFP Budget Workbook Crosswalk.pdf Crosswalk: MFP_Budget_Workbook	IC Document
MFP_MOE_Form_Crosswalk.pdf Crosswalk: MFP MOE Form	IC Document
MFP_MOE_Form_Crosswalk.pdf Crosswalk: MFP MOE Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Administrative Requirements for Section 6071 of the DRA

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10249	Yes	Yes	Fillable Fileable
Form	CMS-10249	Yes	Yes	Fillable Printable
Instruction		Yes	Yes	Fillable Printable
Form	CMS-64.9i, -64.9pi, -64.10i, and -64.910pi,	Yes	No	Fillable Printable
Form and Instruction	CMS-10249	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10249	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	336	-16	352
Annual IC Time Burden (Hours)	2,604	-564	3,168
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Semi-Annual Progress Report		07/22/2021
Crosswalk: Additional Benchmarks â Addendum to the MFP Semi-Annual Progress Report		07/22/2021
Crosswalk: MFP_Semi-Annual_Help_File		07/22/2021
Crosswalk: MFP_Budget_Workbook		07/22/2021
Crosswalk: MFP MOE Form		07/22/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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