Information Collection

Part D Expenditure Report

IC 260460 under ICR 202305-0915-007 · OMB 0915-0390.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0390 can be found here:

Documents and Forms

Document Name Document Type
Form 4 Part D Expenditure Report Form
4 Part D Expenditure Report Part D Expenditure Report.xlsx Form
4 Part D Expenditure Report Part D Expenditure Report.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Part D Expenditure Report	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	4	Part D Expenditure Report	Part D Expenditure Report.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 116	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	116	116
Annual IC Time Burden (Hours)	464	464
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.