Information Collection

Exemption Applications - Eligibility for Exemptions

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.