Information Collection

State Implemented Moratorium Form

IC 224647 under ICR 202301-0938-007 · OMB 0938-1328.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1328 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10628 State Implemented Moratorium Form	Form and Instruction
CMS-10628 State Moratoria Request Form CMS-10628-State Moratorium Form-508.pdf	Form and Instruction
CMS-10628 State Moratoria Request Form CMS-10628-State Moratorium Form-508.pdf	Form and Instruction

IC Title:

State Implemented Moratorium Form

Agency IC Tracking Number:

CPI - 10628

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 455.470

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-10628	State Moratoria Request Form	CMS-10628-State Moratorium Form-508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5	-10	15
Annual IC Time Burden (Hours)	25	-50	75
Annual IC Cost Burden (Dollars)	0	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.