Form CMS-10433 Administrative Data Template

Accreditation and Admin Webpage Screenshots

OMB control number 0938-1187
Expiration Date: xx/xx/xxxx

Figure 1: Administrative Page (Edit Issuer General Information)

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1187, expiration
date is xx/xx/xxxx. The time required to complete this information collection is estimated to take up to 282.25 hours per
issuer per year, including the time to review instructions, gather the information needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Figure 2: Administrative Page (Edit Issuer Marketplace Information)

Figure 3: Accreditation Page (Part 1)

Figure 4: Accreditation Page (Part 2)

Figure 5: Accreditation Page (Part 3)
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