Information Collection

Beneficiaries

IC 257780 under ICR 202301-0938-003 · OMB 0938-1441.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1441 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10831 Beneficiaries Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program_508 (CMS-4101-P version 2.pdf Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program_508 (CMS-4101-P version 2.pdf Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program_508 (CMS-4101-P version 2).pdf Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program_508 (CMS-4101-P version 2).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Beneficiaries	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10831	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program	Application to Enroll in the LI NET Program_508 (CMS-4101-P version 2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program	Direct Reimbursement Request for the LI NET Program_508 (CMS-4101-P version 2).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36,982	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36,982	36,982
Annual IC Time Burden (Hours)	9,246	9,246
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.