Information Collection

Exemption Applications - Eligibility for Exemptions

IC 205753 under ICR 202403-0938-005 · OMB 0938-1190.

Documents and Forms

Document Name Document Type
Form CMS-10466 Exemption Applications - Eligibility for Exemptions Form and Instruction
CMS-10466 Application Exemptions Shared Responsibility for FFM's Appendix C - Affordability-SBE-Exemptions-Application.pdf Form and Instruction
CMS-10466 Application Exemptions Shared Responsibility for FFM's Appendix C - Affordability-SBE-Exemptions-Application.pdf Form and Instruction
CMS-10466 Exemption Application - Shared Responsibility SBM's Appendix B - Affordability-FFM-Exemption-Application.pdf Form and Instruction
CMS-10466 Exemption Application - Shared Responsibility SBM's Appendix B - Affordability-FFM-Exemption-Application.pdf Form and Instruction
CMS-10466 Application Exemption - Hardships Appendix A - Hardship-Exemption-Application (2).pdf Form and Instruction
CMS-10466 Application Exemption - Hardships Appendix A - Hardship-Exemption-Application (2).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Exemption Applications - Eligibility for Exemptions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.620 45 CFR 155.610 45 CFR 155.615 45 CFR 155.625

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10466	Application Exemptions Shared Responsibility for FFM's	Appendix C - Affordability-SBE-Exemptions-Application.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Exemption Application - Shared Responsibility SBM's	Appendix B - Affordability-FFM-Exemption-Application.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10466	Application Exemption - Hardships	Appendix A - Hardship-Exemption-Application (2).pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 849	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	849	-44,151	45,000
Annual IC Time Burden (Hours)	229	-11,921	12,150
Annual IC Cost Burden (Dollars)	0	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.