Information Collection

Beneficiaries

IC 257780 under ICR 202304-0938-019 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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 (CMS-4201-F version 3).pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program (CMS-4201-F version 5).pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program (CMS-4201-F version 3).pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program (CMS-4201-F version 5).pdf	Form and Instruction

IC Title:

Beneficiaries

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10831	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program	Application to Enroll in the LI NET Program (CMS-4201-F version 5).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 (CMS-4201-F version 5).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 %

table that charts list of burden
	Approved	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

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.