Information Collection

Income and Eligibility Verification System Reporting and Supporting Regs.

IC 8090 under ICR 202204-0938-011 · OMB 0938-0467.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0467 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-74 Income and Eligibility Verification System Reporting and Supporting Regs.	Form
CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification S IncomeEligibilitySPAPreprintclm508.pdf	Form
CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification S IncomeEligibilitySPAPreprintclm508.pdf	Form

IC Title:

Income and Eligibility Verification System Reporting and Supporting Regs.

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 431.306 42 CFR 435.940-435.960 42 CFR 435.920 42 CFR 431.17 42 CFR 435.910

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	CMS-R-74	Attachment 4.32-A: Income and Eligibility Verification System (IEVS) - PARIS SPA Template	IncomeEligibilitySPAPreprintclm508.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Previously Approved
Annual Number of Responses for this IC	3,241	3,241
Annual IC Time Burden (Hours)	1,082	1,082
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.