Form CMS-10184 Monthly Sample Selection List

OMB Approval #0938-1012

Expires XX/XX/XXXX

Payment Error Rate Measurement (PERM)

Due on the 15^th day of the month after the sample month and before the eligibility reviews begin.

Monthly Sample Selection List
State
Date
Program
Sample Month and Year
	Stratum 1 Applications	Stratum 2 Redeterminations	Stratum 3 All Other Cases	Negative Cases
Number of cases in universe that month
	Case/Beneficiary ID	Case/ Beneficiary ID	Case/ Beneficiary ID	Case/ Beneficiary ID
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PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1012.  The time required to complete this information collection is estimated to average [1000 hours] per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained.

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