OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

State Plan Under Title XIX of the Social Security Act (Base plan pages)

IC 7877 under ICR 202108-0938-008 · OMB 0938-0193.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-179
State Plan Under Title XIX of the Social Security Act (Base plan pages)		 Form and Instruction
CMS-179 Transmittal and Notice of Approval of State Plan Materia
CMS 179 Transmittal Form and Instructions (2021 e-version 1).pdf 		Form and Instruction
CMS-179 Transmittal and Notice of Approval of State Plan Materia
CMS 179 Transmittal Form and Instructions (2021 e-version 1).pdf 		Form and Instruction
CMS-179 2.1 - 2.7 (State)
Exhibit A 508 (rev OSORA PRA).pdf 		Form
CMS-179 2.1 - 2.7 (State)
Exhibit A 508 (rev OSORA PRA).pdf 		Form
CMS-179 2.1 - 2.7 (Territory)
Exhibit A1 508 (rev OSORA PRA).pdf 		Form
CMS-179 2.1 - 2.7 (Territory)
Exhibit A1 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(a)
Exhibit AA 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(a)
Exhibit AA 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(e)
Exhibit AB 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(e)
Exhibit AB 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(f)
Exhibit AC 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(f)
Exhibit AC 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(g)
Exhibit AD 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(g)
Exhibit AD 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(h)
Exhibit AE 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(h)
Exhibit AE 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(i)
Exhibit AF 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(i)
Exhibit AF 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19 (k)(1)
Exhibit AG 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19 (k)(1)
Exhibit AG 508 (rev OSORA PRA).pdf 		Form
CMS-179 Attachment 2.2 A and Supplements 1 - 3
Exhibit D and E 508 (rev OSORA PRA).pdf 		Form
CMS-179 Attachment 2.2 A and Supplements 1 - 3
Exhibit D and E 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(b): Attachment 4.19 B
Exhibit DP 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(b): Attachment 4.19 B
Exhibit DP 508 (rev OSORA PRA).pdf 		Form
CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5,
Exhibit F and G 508 (rev OSORA PRA).pdf 		Form
CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5,
Exhibit F and G 508 (rev OSORA PRA).pdf 		Form
CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4,
Exhibit H and J 508 (rev OSORA PRA).pdf 		Form
CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4,
Exhibit H and J 508 (rev OSORA PRA).pdf 		Form
CMS-179 Attachment 4.19-B, Section 24
Exhibit N 508 (rev OSORA PRA).pdf 		Form
CMS-179 Attachment 4.19-B, Section 24
Exhibit N 508 (rev OSORA PRA).pdf 		Form
CMS-179 Attachment 4.19 B, Supplement 1
Exhibit O 508 (rev OSORA PRA).pdf 		Form
CMS-179 Attachment 4.19 B, Supplement 1
Exhibit O 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(c)
Exhibit P 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(c)
Exhibit P 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(d)
Exhibit Y Revision 4-9-15 (rev OSORA PRA).pdf 		Form
CMS-179 4.19(d)
Exhibit Y Revision 4-9-15 (rev OSORA PRA).pdf 		Form
CMS-179 4.31, 4.32, 4.33, and 4.34
Exhibits R S T U 508 (rev OSORA PRA).pdf 		Form
CMS-179 4.31, 4.32, 4.33, and 4.34
Exhibits R S T U 508 (rev OSORA PRA).pdf 		Form
CMS 179 Transmittal Form and Instructions (2021 e-version 1) CROSSWALK.pdf
CROSSWALK: Transmittal and Notice of Approval of State Plan Material		IC Document
CMS 179 Transmittal Form and Instructions (2021 e-version 1) CROSSWALK.pdf
CROSSWALK: Transmittal and Notice of Approval of State Plan Material		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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-179 Transmittal and Notice of Approval of State Plan Material CMS 179 Transmittal Form and Instructions (2021 e-version 1).pdf Yes Yes Fillable Fileable
Form CMS-179 2.1 - 2.7 (State) Exhibit A 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 2.1 - 2.7 (Territory) Exhibit A1 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(a) Exhibit AA 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(e) Exhibit AB 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(f) Exhibit AC 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(g) Exhibit AD 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(h) Exhibit AE 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(i) Exhibit AF 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19 (k)(1) Exhibit AG 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 Attachment 2.2 A and Supplements 1 - 3 Exhibit D and E 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(b): Attachment 4.19 B Exhibit DP 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5, 5a, 6, 7, 8, 8a, 8b, 8c, 9b, 10, 11, 12, 13, 14, and 15 Exhibit F and G 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, 7, 8a, 8b, 8c, 9b, 11, 12, 14, and 15 Exhibit H and J 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 Attachment 4.19-B, Section 24 Exhibit N 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 Attachment 4.19 B, Supplement 1 Exhibit O 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(c) Exhibit P 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.19(d) Exhibit Y Revision 4-9-15 (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-179 4.31, 4.32, 4.33, and 4.34 Exhibits R S T U 508 (rev OSORA PRA).pdf Yes Yes Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,120 0 0 0 0 1,120
Annual IC Time Burden (Hours) 22,400 0 0 0 0 22,400
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
CROSSWALK: Transmittal and Notice of Approval of State Plan Material CMS 179 Transmittal Form and Instructions (2021 e-version 1) CROSSWALK.pdf 08/25/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.